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Foot and Ankle Biomechanics

Jeffrey D. Towers, M.D.,1,2 Christopher T. Deible, M.D.,1 and Sara K. Golla, M.D.1

ABSTRACT

With the advent of imaging advancements there has been renewed interest in
the foot and ankle. However, many of the basic functions and biomechanical considera-
tions of the bones, joints, and specialized tissues of the normal and dysfunctional foot and
ankle remain unfamiliar to many radiologists. This article focuses on the basic biome-
chanics, normal alignment, and common alignment disorders of the foot and ankle that
are relevant to radiologists.

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KEYWORDS: Foot biomechanics, foot alignment disorders, ankle biomechanics

TERMINOLOGY GAIT AND BIOMECHANICS


Although clinical and anatomic descriptions of alignment OF THE FOOT AND ANKLE
have evolved with somewhat disparate terms, most terms There are two things the foot and ankle must do: be-
can be applied to the standard three-axis, X-Y-Z coor- come flexible to absorb load and become rigid to act as a
dinate system. Using this system, the description of mo- lever arm. A brief review of the gait cycle underscores
tion can be agreed upon by rotational movement about these tasks (Table 1).1–4,6 The walking cycle can be
these axes (Fig. 1).1–5 It is important to note that the roughly divided into two portions, the stance phase in
movement of the foot and ankle is multiplanar, and these which the foot is on the ground and the swing phase when
individual components of motion occur simultaneously it is off the ground.
in a coordinated and synchronized fashion, not as indi- The stance phase comprises about 60% of the
vidual movements in isolation. gait cycle and is initiated by heel strike.1–4,6 Transfer of
Motion in the sagittal plane, about the horizontal the body load to the foot, which must be absorbed to
or X-axis, is described as plantarflexion and dorsiflexion.1–5 prevent injury, characterizes the heel strike portion of
Varus and valgus are the terms we use to describe move- the stance phase. Load is absorbed in the skeletal sys-
ment in the axial plane, or rotation about the cephalo- tem by angular motion of joints resisted by muscles in
caudad Y-axis, and refer to either medial (varus) or lat- eccentric contraction, that is, contraction occurring while
eral (valgus) alignment of the distal portion of the the muscle is lengthening. It is directly analogous to lever
structure relative to the proximal. Abduction and adduc- arm shock absorbers that were used on British sports
tion may be used as well, but some landmarks for these cars prior to the advent of telescopic shocks. Accord-
terms refer to the body and some to the center of the ingly, flexibility is paramount for accommodating load
foot, resulting in confusing situations (e.g., abductor hal- in this phase of walking and occurs in the knee, ankle,
lucis is really an adductor). Inversion and eversion are and foot.
terms we use to describe motion in the coronal plane, or As stance progresses, the body mass continues to
rotation about the anteroposterior Z-axis. Supination and move forward over the fixed foot and initiates toe-off,
pronation are often synonymous with these latter terms the second portion of the stance phase.1–4,6 This portion
but may also refer to motion combining adduction, plan- of the stance phase requires that the foot become a rigid
tarflexion, and inversion (supination) or abduction, dor- lever arm to support the load generated from the ankle
siflexion, and eversion (pronation). across the metatarsals that propels the body forward.

Biomechanics; Editors in Chief, David Karasick, M.D., Mark E. Schweitzer, M.D.; Guest Editor, Jeffrey D. Towers, M.D. Seminars in
Musculoskeletal Radiology, Volume 7, Number 1, 2003. Address for correspondence and reprint requests: Jeffrey D. Towers, M.D., UPMC Health
System, Department of Radiology, 200 Lothrop Street, Pittsburgh, PA 15213. 1Department of Radiology; 2Department of Orthopaedic Surgery,
University of Pittsburgh Medical Center, Pittsburgh, PA. Copyright © 2003 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New
York, NY 10001. Tel +1(212) 584-4662. 1089-7860,p;2003,07,01,067,074,ftx,en;smr00280x
67
68 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 7, NUMBER 1 2003

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A B
Figure 1 (A, B) Foot and ankle motion.

These seemingly contradictory tasks of flexibility valgus at the hindfoot-midfoot junction and varus at the
and rigidity all must occur at the correct times within a midfoot-forefoot junction. This Z-configuration allows
stance phase that lasts about two-thirds of a second in angular motion in the horizontal plane. In coronal sec-
normal walking. tion, the foot is relatively vertical in the hindfoot, with
an asymmetric arch becoming shallower and more hori-
zontal as the forefoot is approached.
NORMAL ALIGNMENT AND
BIOMECHANICS
The overall configuration of the foot and ankle from a Ankle
lateral view is a truss with a short posterior and long an- The ankle has an articular configuration of a conic sec-
terior joist forming the longitudinal arch.1–5,7,8 A ten- tion held in external rotation to the tibial plafond, with
sion arm along its plantar surface joins these, the plantar the foot internally rotated with respect to the ankle.1–5,7,8
aponeurosis, and is dynamic rather than static being at- It provides the majority of plantar and dorsiflexion and
tached to the plantar plate at the metatarsophalangeal considerable internal rotation in concert with the subta-
joints forming a windlass mechanism. From an antero- lar joint. It is stabilized by the deltoid ligament medially
posterior view, a series of angled joints are evident, with and the lateral collateral ligaments laterally. Its asym-

Table 1 Lower Extremity Activity During the Gait Cycle


Pelvis Femur Tibia Internal Rotation External Rotation Internal Rotation

Ankle joint Plantarflex Dorsiflexion Dorsiflexion


Plantarflex
Subtalar joint Eversion Inversion Eversion
Choparts joint Unstable Increasingly stable Unstable
Intrinsic muscles Inactive Increasingly active Inactive
Pretibial muscles Active Inactive Active
Calf muscles Inactive Active Inactive
Cycle Heel strike Midstance—Toe off Swing
FOOT AND ANKLE BIOMECHANICS/TOWERS ET AL 69

metric surface provides greater stability in dorsiflexion comes shallower by hindfoot pronation, increasing its
and greater mobility to inversion and eversion in plan- flexibility, and steeper in supination, making it more rigid
tarflexion. in preparation for toe-off.

Subtalar Joint Tarsometatarsal (Lisfranc’s) Joint


The subtalar joint usually has three facets and provides Lisfranc’s joint is relatively rigid, with some capacity for
eversion, inversion, and internal rotation. It is stabilized varus of the first ray.1–5,7,8 Strong ligaments traversing
by components of the deltoid and lateral collateral liga- intertarsal, tarsometarsal articulations, and a mortise and
ments, the interosseous ligaments of the sinus tarsi, and tenon configuration of the second ray contribute to a
by its lateral capsule.1–5,7–10 The lateral position of the transverse arch and longitudinal arch that support the
calcaneal posterior process with respect to the talus pro- metatarsals in toe-off. The peroneus longus attachment
vides a lever arm for eversion (pronation) during heel to the lateral base of the first metatarsal provides dy-
strike and midstance, whereas the sustentaculum tali pro- namic resistance to first ray varus and excessive prona-
vides a lever arm for inversion (supination) in late stance tion of the forefoot during toe-off.
and toe-off (Fig. 2).

Metatarsophalangeal (MTP) Joints


Transtarsal (Chopart’s) Joint A metartarsal break angle from the second to fifth ray

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Plantarflexion and dorsiflexion are major components of metatarsal head defines the angle of dorsiflexion of these
this joint, which has a variable range of motion, depend- joints (Fig. 3).1–5,7,8,12–17 Beginning at the lateral toes,
ing upon the degree of subtalar rotation and version, and loading moves medially, ending between the first and sec-
is largely responsible for providing flexibility or rigidity ond ray. The plantar plate helps to prevent intermetatarsal
of the midfoot.1–5,7,8 During heel strike, pronation (ever- divergence during loading of the forefoot. In addition,
sion-valgus) of the subtalar joint makes the rotational progressive dorsiflexion of the MTP joints during toe-off
axes of the talonavicular and calcaneocuboid joints rela- activates the windlass mechanism of the longitudinal arch
tively parallel, increasing the joint’s range of motion. In of the foot by the connection of the plantar aponeurosis
late stance phase, supination (inversion-varus) moves the to the MTP capsules, which progressively steepens the
articular surfaces into a relatively antiparallel arrange- anteroposterior arch during forefoot loading, adding fur-
ment, increasing rigidity of the midfoot. ther rigidity. Dorsiflexion reappears just before the next
heel strike, during which it is actively resisted with load-
ing of the hindfoot, further absorbing load (Fig. 4).
Intertarsal Joints
The naviculocuboid, naviculocuneiform, and intercunei-
for joints form a variably pitched roman arch in the Plantar Fat
midfoot, which is altered by the dynamic alignment of The plantar fat in the foot is especially compartmental-
the hindfoot.1–5,7,8,11 In addition to the relative flexibil- ized with swirls of fascia surrounding lobules of fat, with
ity or rigidity of Chopart’s joint, the intertarsal arch be- superficial microchambers and deep macrochambers (Fig.

A B
Figure 2 (A, B) The mitered hinged configuration of the subtalar joint provides linkage between pronation of the foot and internal
rotation of the ankle during loading.
70 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 7, NUMBER 1 2003

A B
Figure 3 (A) Metatarsal break angle. (B) A long second toe alters toe-off mechanics.

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5).2–5,7,8,18,19 The structure works to dissipate load, par- midfoot, allowing greater flexibility. There is progressive
ticularly over the bony eminences of the heel and metar- midfoot valgus as loading continues that is resisted by
sophalangeal joint. The fat structure works best when the medial flexors, especially posterior tibialis. The wind-
more of its surface is loaded, as when shoes are properly lass mechanism is progressively unwound against resis-
fitted with a tight heel cup, which allows more of the tance by extensor muscles, further absorbing load. As
lateral surfaces to dissipate load. With poorly fitted shoes midstance progresses, the tarsometatarsal joint allows
or injury, the fat cells may become inflamed or fibrotic, some varus and dorsiflexion of the first ray, further ab-
leading to abnormal loading of underlying bone and ar- sorbing load.
ticular structures. In preparation of toe-off, the flexor tendons con-
tinue to contract as the load on the heel reduces, pulling
the hindfoot into supination (inversion-varus) by action
Normal Gait of posterior tibialis.1–4,6 This makes the trantarsal joint
With heel strike, the lateral position of the posterior pro- surfaces more antiparallel, and hence more rigid, and
cess of the calcaneus causes pronation (eversion-valgus) makes the cross-sectional arch steeper and more rigid as
of the hindfoot with internal rotation of the ankle.1–4,6 well. As toe-off progresses, the medial flexors are matched
The knee and hip also internally rotate in response. by contraction of the lateral flexors, which stabilize the
Pronation allows greater mobility of the transtarsal joint first ray through contraction of peroneus longus and
by making its surfaces relatively parallel, which allows maintain position in the lateral column by contraction
dorsiflexion and widens the cross-sectional arch of the of the peroneus brevis. Intrinsic flexor muscles also con-

A B
Figure 4 (A, B) Windlass mechanism of the longitudinal arch. At toe-off progressive plantarflexion of the MTP joints tightens the
plantar aponeurosis, increasing the height of the longitudinal arch and providing greater rigidity.
FOOT AND ANKLE BIOMECHANICS/TOWERS ET AL 71

A B
Figure 5 (A) Sagittal and (B) coronal MR images of the heel pad demonstrating load distribution.

tribute to forefoot rigidity, and the windlass mechanism sive, painful planovalgus, posterior tibial dysfunction is
is tightened as MTP flexion proceeds. usually present and the degree of deformity correlates to
the degree of tendon tear and lengthening.

COMMON ALIGNMENT ABNORMALITIES


Alignment abnormalities are best derived from clinical

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Pes Cavus
measurements and weight-bearing anteroposterior and The high-arched foot is characterized by a talometa-
lateral radiographs. Non–weight-bearing radiographs and tarsal angle pointing dorsally and usually has varus align-
sectional images may suggest alignment disorders but ment as well and thus is often referred to as a cavovarus
often over- or underestimate deformities. deformity (Fig. 7).2,5,7,8,20–24 It is more rigid than nor-
mal and thus is prone to arthrosis from the inability to
absorb load. Heel and MTP loading may be excessive
Pes Planus with plantar fasciitis and forefoot fat fibrosis.2,5,7,8,25 Ad-
Defined by the talometatarsal angle pointing plantar- ditionally, in individuals who are active in loaded plan-
ward, planus feet generally have components of planus tarflexion (such as ballerinas en-pointe) cavus at Lis-
and valgus and are often referred to as a planovalgus de- francs joint may lead to abnormal longitudinal load in
formity (Fig. 6).2,5,7,8,20–24 They are more flexible than particular.26,27 A major consideration in the cavus foot is
normal and therefore can absorb load well. Their pri- neuropathy.28,29 In the forefoot, excessive varus may allow
mary problem is in becoming and/or maintaining rigid- greater than normal loading of the lateral metatarsals,
ity in toe-off. In the middle-aged patient with progres- with “rolling over” the metatarsals, preventing the greater
load in late toe-off from getting to the medial greater
metatarsals. Stress reactions and occasional fractures may
be seen.

Tight Heel Cord


An overly tight Achilles causes loading of the forefoot
earlier in the stance phase than normal, before the events
providing and maintaining rigidity of the mid- and
A

B
Figure 6 Lateral radiographs demonstrating (A) normal align-
ment and (B) pes planus with talometatarsal angle pointing Figure 7 Lateral radiograph demonstrating pes cavus with
plantarward. talometatarsal angle directed dorsally.
72 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 7, NUMBER 1 2003

A B

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Figure 8 (A) Normal Achilles tendon and align-
ment. (B, C) A tight heel cord causes “toe walk-
ing” and eversion and loading prior to attaining a
C rigid lever arm.

forefoot are achieved.2,5,19 Characterized by “toe walk- lack of a competent lever arm as well as plantar bony
ing,” it is exacerbated by wearing high heels, which pre- prominences, usually at the cuboid, termed the “rocker
vent normal stretching of the gastrocnemeus and soleus bottom” deformity.
muscles and leads to abnormal forefoot load (Fig. 8). More troublesome is the “midfoot sprain” often
Loading in plantarflexion allows greater than normal treated by brief immobilization. This often represents a
valgus at the ankle joint and excessive direct loading of Lisfranc dislocation with spontaneous reduction.30,31 Al-
the metatarsal heads and is thought to predispose to though no static deformity can be seen on non–weight-
Freiberg’s infraction or osteonecrosis of the metatarsal bearing films in the acute setting, significant valgus defor-
heads. mity with even modest loading is typical. Weight-bearing
or stress views (particularly after anesthetic injection)
often reveal the deformity, warranting rigid fixation and
Hypermobile First Ray prolonged immobilization to allow collagen maturation
Metatarsum primum varus may be intrinsic or due to sufficient to bear load (Fig. 9). CT examination in the
weak flexion by the peroneus longus.2,5,7,13 It allows not acute setting may show entheseal avulsions indicating lig-
only varus but also dorsiflexion of the first metatarsal, ament injuries in individuals who cannot bear weight.
which in turn allows forefoot pronation during toe-off. Failure to recognize this entity results in a planus midfoot
These contribute to the association with hallux valgus, in which fitting shoes is very difficult and in which
in which the great toe attains progressive valgus angula- arthrosis almost uniformly occurs.
tion from medial loading during toe-off, with lateraliza-
tion of the sesamoids, medial eminence formation, and
arthrosis. CONCLUSION
The normal daily function we expect from our feet and
ankles requires a careful balancing of mobility and sta-
Dislocations bility. Complex structures consisting of interconnected
Virtually all dislocations of the foot result in dorsal po- articular surfaces, bones, and soft tissues, the foot and
sitioning of the distal fragment, as the anterior joist of ankle are critical to activities of daily living and quality
the sagittal truss breaks down, allowing the posterior of life. By understanding the basic biomechanics of the
structure to “plow” beneath the structure directly in front foot and ankle the radiologist can more fully appreciate
of it.2,5,7,10,27,30 In the neuropathic foot, this leads to a and understand the morphology and function presented
FOOT AND ANKLE BIOMECHANICS/TOWERS ET AL 73

A B C
Figure 9 AP foot radiographs demonstrating (A) normal alignment, (B) Lis Franc fracture dislocation, and (C) fracture dislocation

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with stress view.

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