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Action of the Subtalar and Ankle-Joint Complex During the Stance Phase of Walking
D. G. WRIGHT, S. M. DESAI and W. H. HENDERSON J Bone Joint Surg Am. 1964;46:361-464.
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Publisher Information
Action
of the
Subtalar
and
Ankle-Joint
Complex
During
BY D. G.
the
HENI)ERSON, Laboratory,
Stance
M.D.f,
Phase
s.
SAN i.
of Walking
DESAI, M.E4, AND CALIFORNIA San Francisco and Berkeley
WRIGHT,
W. H.
From tile Biomechanics
B.54, University
FRANCISCO, of California,
study, between
rotation
a continuation
shoe
about
of previous
leg during the
work
staimce
on
phase
human
of
and
walking
locomotion was
2,3,4,5,9
analyzed
jIm terimms
the
axes
of the
and
ankle
joints.
Location
It
is generally
believed
that
motion
subtalar
and
joints
closely
that of a simple hinge and of motion. The location of these it may be said that the axes are
ankle
traimsversely through the body to time talus and runs obliquely Hicks did a comprehensive of ankle to
distal
posterioi
of the talus ; and the downward, outward, study of this subject and axis. one in plantar also
the oblique
subtalar axis is located distal and backward. (Fig. 1). He found two axes flexion. found
mid-tarsal,
nmotion, as a single
to time talus:
one
will
be referred immediately
here
Hicks
time talocalcaneonavicular,
nmid-tarsal (Fig. 1). The first two have imearly ideimtical actions. Hicks referred to timem together as time oblique hinge ; they will be referred to imere as time subtalar axis. The other axes described by Hicks, includiimg the aimtei-oposterior mid-tai-sal, ai-e comcerned only with motion of the fore part on the hind part of the
foot
studies timese in
here, Hicks
a firm locatirnm
shoe to be of
was
t.imese
by the
absent.
1.8
considered
pi-actically
agreement
rotated
plaime
to note (Fig. 1) that the ankle axis lies in a Imorizontal in this plane so that it is oblique to the frontal plane
subt.alar axis usually forms aim angle of 10 to IS
8#{149}
obliquely
sagittal
located
degrees
and
45 degrees
Terminology
witim the
horizoimtal
plane
of the
foot
Coimsiderable
of
confusioim
exists
in the
terminology
used
to describe
the
two.
and its joints. Often there is inadequate distinction nmade In this paper, we slmall use two different sets of terms to distinguish
foot
nmeimts from
version-eversion,
joint
movenmemits. and terms in anatonmical abduction-adductioim, writing, are do-siflexion-plaiitaiused to describe planes. transversely axis
Time traditional
time foot relative to time sagittal, frontal, Immalmner, immovement about a hypothetical would
*
be
TEiiis
Faster
doi-siflexion-plantar
inVestigation Seal I)uIl(1ation
Marston
flexion,
supported (1r:ttit
1.)rive,
a vertical
Administration
be
abductionVIOO5M-2075
was
lI1(l
VJ-29.
Anchorage,
LaI.)orat.ory,
University
\Iedical
Center,
8:111
}rancisco,
Cali-
94122.
46-A, NO. 2. MARCH 1964
361
362
D.
G.
WRIGHT,
S.
M.
DESAI,
AND
W.
H.
HENDERSON
in the ankle
As mentioned foot do not combines subtalar plantar called or the and and
with combines
axis
motion
with a slight degree dorsiflexion-abduction-eversion in the other. respectively, to speak Negative recorded
flexion-adduction
These subtalar motions in traditional terms. about appears the as a joint axes downward
been negative
have rotation.
chosen
deflection
on
of rotation
plantar
rotation dorsi-
fiexion-abduction-eversion. that has occurred about done in terms of angular cussed later.
it is necessary to describe the amount of rotation at a given instant in the walking cycle, it will be relative to a neutral position which will be dis-
Orientation
Scale
10cm.
T.
,d.a.
Fm.
Location
of joint
axes.
The
axes
of all the
foot
adapted
standing,
from
roentgenograms
of the
experimental
of moderate the first ray
foot.
Foot
in basic
position
of relaxed
flat
extension, the talocalcaneonavicular and midtarsal at full extension-supination, and the fifth ray near to full flexion-supination. d.a., dorsiflexion ankle axis; p.a., plantar flexion ankle axis; ten., talocalcaneonavicular axis; o.m.t., oblique mid-tarsal axis; a.p.m.t., anteroposterior mid-tarsal axis; lr., first ray axis; 5r., fifth ray axis. (Reprinted from The Mechanics of the Foot: I. The Joints by J. H. Hicks. J. Anat., 87 : 350, 1953.)
THE JOURNAL OF BONE AND JOINT SURGERY
ACTION
OF
THE
SUBTALAII
AND
ANKLE-JOINT
COMPLEX
31;::;
PLANE
OF MOTION
PLANE
PERPENDIGULR
OF MOTION
TO X-AXIS
PERPENDICULAR
TO NEITHER
AXIS
TOP
VIEW
SI DE
VIEW
(a)
FIG.
(b)
2 joint. l)iagranm of uniersal
VOL.
46-A,
NO.
2, MARCh
1964
364
D.
G.
WRIGHT,
S.
M.
DESAI,
AND
W.
H.
HENDERSON
Action
The The manner
of a universal
of Axes
permits can
a joint, with
subtalar
joint.
and
ankle-joint this
2 shows
complex
such
flexion
its two
of the through
axes,
foot
x and
on the
the
leg.
in which
analogy joint on
Figure
y. Through
member
of the exclusion
2,a)
(x) to the
other axis
axis
(y) about
(y)
accomplished
only
plane stated
of motion differently,
When
is perpendicular no rotation
is imposed
the
the
which
motion.
a rotation
system in a plane that is perpendicular part about each axis (Fig. 2,b) The
.
to amount
rotation occurring
will take place iim about eaclm axis is to the plane of but illus-
a function
motion.
of how closely that axis approximates This analogy to the ankle-subtalar joint mechanical principles involved.
trates
the
is applied to the shoe and leg relationships, the shoe, or foot, of the joint; the leg, the other; and the subtalar and ankleinterposed axes. In flexion of the leg on the shoe, the plane of the how much of the motion occurs In ordinary walking, the ankle
of the motion.
motion much
to for the
leg on the
It was
shoe,
shown
and
rotation
1.7,8
most
not
perfectly
long
axis
of the
foot
around timis axis accounts that the ankle axis is or to the plane of motion; subtalar actioim axis. of the
therefore, Two
because it is fixed to the floor by body weight. Therefore, this tibial rotation must be resolved at the subtalar or ankle axis. The ankle axis lies within the Imorizontal plane of this motion. Thus, this motion of the tibia cannot be resolved about the ankle axis and interimal rotation which the takes place wholly of the tibia acts about through plantar the axis of the subtalar joiimt ; therefore, the subtalar axis to produce pronation of the flexion. foot The relative triceps to the leg. surae, in plantar flexing
the foot in a plane rotation may be entirely accomplished foot as a lever is preserved by other subtalar joint.
to the ankle-joint axis. This joint, and the integrity of the provide immobilization of the
Forces
Figure
function
and forces
Displacements and joints displacements during walking. that are This associated information of California cycle. During
2,9
3 shows of the
some
of the and
with is
subtalar
ankle
derived Some
from previous locomotion studies done at the University of these findings may be summarized briefly here: Stance phase occupies the first 60 per cent of the walking
timis
phase the tibia, as it moves forward over the foot, remains in a parasagittal plane, not deviating medially or laterally (Fig. 3,B and C). From 0 to 15 per cent of the cycle, the foot plantar flexes on the leg and is placed flat on the ground (Fig. 3,C); the anterior internally
this period
this motion (Fig. 3,F) ; the tibia rotates applied to the foot until by the end of
body
THE
is supporting
weight
JOURNAL
(Fig.
OF
3,
BONE
D).
AND
At
15 per
cent
JOINT
SURGERY
ACTION
OF
TILE
SUBTALAIt
ANI)
ANKLE-JOINT
COMPLEX
365
of the
exterimally
cycle
timere and
gait
patterns, 3,C)
15 The
of the toi-que
time foot
postei-ior nmuscles of time leg simow progressively latter half of timis pei-iod, umitil nmaxilmmiiimi activity
cycle
(Fig. 3,G).
greatei activity throughout the is i-cached at 45 per cemmt of the replaced by plantar D). 1)uring the end
vei-tical force
Dorsiflexiomi
of
time
foot
ott
the
immaxiimmunm vertical
phase,
force
foot
is developed
flexing
leg (lig.
sharply,
wheit
time
is plantar
and
immuscie activity
fall oil
G).
:cc.
PER
#{149}EL
CENT OF WALKING CYCLE
#{174}
20
40
60
80
00
TIBIALROTATION-TOPVIEW
XI-
c.0 40 60
PER FIG.
CENT
OF WALKING
CYCLE
3 during walking.
Forces
VOl.. 46-A, NO. 2, MARCh
aiid
displacenmetmts
1964
366
D.
G.
WRIGHT,
S.
M.
DESAI,
AND
W.
H.
HENDERSON
Methods
Testing The joint
report
Equipment testing unit used was the mechanical research externally analog of the subtalar and aimkle-
complex developed by the orthotics 6 Briefly, timis device duplicates joiimts. joints 1or this to the simoe When time unit are coiimcident, study, with the unit a stirrup.
is adjusted so timat the axes of time nmechaimithe wearer feels no interferelmce with Imis was attached to the leg witlm a plaster cast in the Potentionmeters ms-ei-e incorporated
( Fig.
FIG.
Mechanical
analog
of
subtalar
axes
so that The
rotations testing
about unit
both
axes
could
be recorded in Figure
is shown
on a subject
to the
equipnment.
heel amid toe contacts and For uphill, downhill, and constructed wimicim allowed
were long enough to permit six or seven consecutive steps. sidehill walking, an adjustable copper-covered ramp was for three consecutive steps.
THE JOURNAL OF BONE ANI) JOINT SURGERY
ACTION
OF
THE
SUBTALAR
AN1)
ANKLE-JOINT
COMPLEX
367
Recording The
almd
traciimgs axis.
of lValking electronic
joints
are simowim
Patterns systeni
K
continuously
walking cycle
recoided
in line the form simows top
the
of
position
three rotation
of
tracings. about
time subtalar
Typical time ankle
ankle
during
the
in
Iiigure
6.
The
tion) The
flection negative time
Aim upward deflectioim occurs ; a dowimward deflection, with nmiddle line represents rotation
occurs rotation toe contact
de-
with
broken
positive
at the makes
(pronation).
rotation (supination) , a downward deflection with The bottom liime shows time imeel contact nmade and
beginning it possible ammd cud, to orieimt respectively, time iotatioimal
iii
of the
plmase. in
This
imeel-aimd-toe
record
relation
to time walkiimg
cycle.
Two
complete
cycles
are
simowim
Im(;. 5 lestitig
uiiit imi
1)1(e
oIl
SUII)j((t.
All
ti-aeings
progress
fi-oimm
left
deflection
to
standard
calil)I-atiomi
was
used
so
timat
omme ceimtimeter
of constalmt one
represemmt.s
8 degrees
in every
of rotation.
along case are
Time paper
time imorizoimtal of time left
speed
scale foot
was
kept
ti-acings elapsed
repieseimts
second
of
from
each
trip
along
the
walkway
(five
consecutive
Results
steps)
from
yet
the
been
showed a imigh degree discarded since the of time first step as presented here of the superimposed
bridge. flie
of similarity (Fig. 7). normal walkilmg speed along time imorizoimtal are
or in time
and
time traciimgs
axis
fm-oimm time others. The tracings curves drawn from the means
*
illustrations recordimmgs
l)otemltionm(!ter
either
typical unit
The
sensing
device
was
a \Viieatstone
elenmemit. iim the bridge circuit. Initial 1)alance (zero output) could 1)05iti11 of the suhtalar or ankle joint. To acimieve balance, a I)oterltionmeter with the transducer. Calibration was effected by selecting tue appropriate series with the op)osing leg. The voltage changes in the circuit were recorded graph, MO(l(l 504 it.
\.OL,. 46-A. NO. 2.
MARC!!
varial)le
be estal)lished at any was adjusted iii series resistance inserted in by an Olimier 1)vno-
1964
368
D.
G.
WRIGHT,
S.
M.
DESAI,
AND
W.
H.
HENDERSON
A typical
series of these
section
tracings
of the
records
obtained The
6 ; Figure line
simows lines
a in the
superimposed.
average ankle
of the joint
7 is represented in Figure 8. neutral position was the position was standing relaxed with the knees
wimen
fully
extended,
at the
sides,
apart, and a comfortable amount of toeing-out. This position was degree of rotation for both joints and was also the position cimosen the electronic recording equipment at zero. This neuti-al position is horizontal straight line passing through all tracings.
ankle
t
positive ANKLE ROTAT ION
negative
t positive
Su BTALAR
STANCE
PHASE
ROTATION
negative
I
FIG.
7
rotations (five consecutive steps).
Superinmposed
records
of ankle
and
subtalar
joint ankle
phase positive
measured
at which
imegative
measured of Toeing-out
of
1\Ieasurement
the
amount
of toeing-out
THE
(abduction)
JOURNAL OF
during
BONE AND
walking
JOINT
was
SURGERY
ACTION
OF
THE
SUBTALAR
ANI)
ANKLE-JOINT
COMPLEX
devices walkway by
to the
heel
and
toe
of the
connecting by
with a line along the center the shoe were then related
and the two means of a was calcufrom the ink calcanei and
axis of the foot was considered heads of the first and second
TABLE
FACTORS AFFECTING AMOUNT
to bisect metatarsals
I
tuber
OF
SUBTALAR
ROTATION
(Average #1 ( Degrees)
Measurements
of Rotation of 20 to 30 Consecutive
Steps)
Run
4/12/60
#2 ( Degrees)
(Millimeters)
Run
4/15/60
#3 ( Degrees)
4/8/60
ions nornmal
(Millimeters)
(Millimeters)
8.3 8.2 7.8 9.4 11.8 3.1 Not done Not done
No
arnm
arnm
swing
swirmg
Exaggerated
Toeing-out Toeing-in
Long stride
Not Not
Short
stride
6.9 6.2
TABLE
EFFECT OF CADENCE ON
II
1)EGREES OF ROTATION
1)GW) Ankle Axis ( Degrees of Rotation) Stance Phase (Duration in Seconds) Cadence (Cycles per Minute)
Axis
Ra1)id
average
gait:
values
steps
average
twelvesteps
values
for
6(6.1) 18(18.4) .96 41
of Axes
on Testing
Unit and others were ankle were assumed to be correct and the had the lay
as described
by Hicks
then made ummtil time subject axes. In order to determine were chosen
was on
assumed
and
the
be
axes,
measured
two
points
wimile
on time unit
the subject.
which
I\Ieasure-
time unit
ments
paper, Time
ere
poimmts
made
so located
in three was
on the
dimensions. dropped
paper
While to
established
the paper
two
subject from
dimensions.
stood each
on a piece point
The third
the
on
was gauge.
VOL.
the points
length (and
of each the
by means defined)
Projections
4k-A, NO. 2. MARCH
of these
1964
D.
G. WRIGHT,
S.
M.
DESAI,
AND
W.
H.
HENDERSON
and
the
way, foot
the could
inclination be determined.
of timese
to the
on Subtalar
first study was to determine walking and what variables unit was adjusted to record
CONTACT
TOE OFF
HEEL
CONTACT
ANKLE ROTATiON
STANCE T
.
PHASE
FOOT
IMMOBILE+
SUBTALAR ROTATION
20
40
60
80
100
CYCLE
(subject DGW),
8
normal walking
Aimkle
mmd subtalar
rotations
during
HEEL
ANKLE
ROTATION
FOOT
IMMOBILE
SUBTALAR ROTATION
FIG.
9 with
THE
Ankle
and
subtalar
rotations
during
walking
toeing-out
JOURNAL OF
(subject
BONE AND
DGW).
JOINT SURGERY
.iCTION
OF
THE
SUBTALAII
ANI)
ANKLE-JOINT
COMPLEX
371
HEELCONTAT
TOEOFF
ROATgN
+FOOT
IMMOBILE
SUBTALAR
______
FIG. Aiikle
1.11(1 sul)talar rotations
(luring
It
axis
was
anticipated
that
increasiimg
the
rotation
of
time
tibia
about
its
loimg
would
immcrease
time amoummt
of subtalar
rotatioim
through
the
mechanism
de-
walking of these
tibia
about
walkiimg.
Lengtlmeimed
greater
were
also
studied
in order
to
observe
the walking
was
effect
of were
cimamiges
Tai)le obtained
all
ItIflS.
placement I gives
data
i)eginnilmg
of each
used
for
commsecutive nmeasui-emmments
staimce iiote phase were
weie
was
during Table
order toeing-in of
the I timat
of positive
by
of the
timat time only deviations explanation for the lack timat their
time
effect
the
foot,
of time other
axial
variables
tibia
probably
being
in time fact
effect
subtalar
depends
axis
as discusse(1 previously. However, during niost of stance dut-itig w-hich the rotations were measured-time shoe with its was fixed to time floor by body weight and very little inotioim was time shoe
cause
foot,
and time floor. The effect nmotion of time shoe relative and imence of the joint axes, If w-e return to the analogy
are imecessary for this
of toeing-in and toeing-out, however, was to the floor i)ut ratimer to alter the position relative to the plane of progiession. of the universal joint (Fig. 2), we see that
principle to apply to the ankle and subtalar
conditions
systeni:
menmber of stance
must know
of the phase
the
1964
system
must
be immobile, the
the
consider
and
only
so must
foot
otlmer
on the
ground;
is moving
vor..
2, MARCH
372
D.
G.
WRIGHT,
S.
M.
DESAI,
AND
W.
H.
HENDERSON
accept plane
3.
3,B that
as a whole; the
tibia under
moves
during imposed
consideration, of one
imposed Effect
system Positions
flexing
conclusions
behave nearly
HEELCONTACT
,
ANKLE ROTATION
_
,::::::::::::::b_
I
STANCE
PHASE
-40H
+FOOT IMMOBILEU#{216}
PER
Ankle
and
CENT
FIG. 11
OF
WALKING
walking
CYCLE
(subject JM).
subtalar
rotations
during
normal
in the axis
rotation
which
is imposed
by
flexion
of time tibia.
Similarly,
immotion
the
these
positioned
assumptions
obtaining
for
various 1
.
axes
relative
to the
plane
of progression.
Figures patteins
patterns
8, 9, and of
were
the in same
or best
curves same
consecutive taken
toeing-out, on the
timat
the
ili a
foot
( broken
ankle with
was lines
iii
the time between the vei-tical duriimg this time, the axis system
markings beimaved
as indicated previously. We have walking lies in time horizoimtal plane plane of the foot.
One
seen that the axis of time amid is externally rotated expect that, as time time ankle axis to the plane of pi-ogressively, while
to the
frontal
would,
toeing-in farther
AND
JOINT
SURGERY
ACTION
OF
THE
SUBTALAII
AN!)
ANKLE-JOINT
COMPLEX
373
HEEL
CONTACT r I
TOE OFF
if
100
+FOOT
IMMOBILE
FIG.
Ankle
and
suhtaiar
rotations
(luring
J\I).
ANKLE ROTATION
IFOOT
IMMOBILE+!
ROTATION
13
walking with toeing-in (subject
J \I).
Jim Figumes
axis of
8 timrougim
joint
10 it can did
be seen
for subject
the amount
DGW
that
rotation of rotation
about
about
this
time about
axis
the
subtalai
increase
as expected.
Time pattern
of rotation
time axis of time aimkle jonmt also changed, but during stance phase was essentially unchanged.
VOL. 46-A, NO. 2, MARCh 1964
374
This study
D.
G. WRIGHT,
5.
M.
DESAI,
AND
W.
H.
HENDERSON
was
repeated
with
second
subject
(JM)
who
imad
an
habitual
His
for
these motion
three
conditions
are increased
shown from
in Figures toeing-iim
11 to
progressively
20
(1)
w
w a:
Lii I6 2
0 I2-
S 5 5
I0
a:
8S .5 S .. .5
_J < Icx
C)
0
0
1__I
8 TOE-OUT
12
I6
20 DEGREES
toeing-out
24
28
DURING
FIG.
WALKING,
14 increased with
Effect
on
subtalar
rotation
of walking
(subject
DGW).
20 U)
5 .5
Lii
c
I2-.. II-
5 5
#{149}
S S
-
S S S 555
a:I6-
S S
0 a: w
-I
8-
z
44
0 0
I 4
12
16
20
24
28
TOE-OUT
Effect on ankle rotation
DURING
FIG.
WALKING,
15
increased
THE
DEGREES
toeing-out
JOURNAL OF
of walking
with
(subject
BONE AND
ACTION
OF
THE
SUBTALAR
AND
ANKLE-JOINT
COMPLEX
375 steps,
was
was
made
irm which
subtalar and
time degree
ankle
of toeing-out,
During
measured
this study,
for many
toeing-out
was but
plotted ankle
agaiimst
rotation.
progressively
iimcreased rotations
by conscious remained
effort. essentially
Subtalar unchanged
rotations (Figs.
as anticipated
HEEL
CONTACT
TOE OFF
HEEL
CONTACT
TOE OFF
RN
IO#{149}
.FOOT
IMMOBLE-4
(a)
INVERTED
ILOWER)
FOOT
Ib)
EVERTED
(HIGHER)
FOOT
I/\
_-----1
.
I
TOE OFF PIEELCOP4TACT
HEEL
CONTACT
TOEOFF
RAN
4FOOT
IMMO8ILE-.#{216}
.+ IO#{149}
.FOOT IMMOBILE
-0.
JL
SUBLAR
a)
Ankle
ASCENT
OF SLOPE
b)
DESCENT
OF
SLOPE
FIG.
amid sul)talar
rotations
(Itiring
2. This
Sidehill
Walking
requires that time uphill
iii
coimditiomm
foot
be placed pimase.
in an attitude
of the
of eversion
foot, acting
and
the
downimill
foot
in inversion
stance
Eversion
results in internal rotatioim of the tibia amid inversion We would, them-efore, expect that, during walking
rewith
time foot everted, time amikle axis would be rotated into a position more nearly perpemidicular to time plane of progm-essiomi and that the opposite would occur with the foot in inversiomi. The rotation about time ankle axis should 1)e greatest in eversion
vol..
46-A, NO. 2, MARCH 1964
376
D.
G. WRIGHT,
S.
M.
DESAI,
AND
W.
H.
HENDERSON
and
inversion
least
motion (The
at the assumption
in of this of
was consistent duriimg both situations. no subjective difference was noted.) recorded of the slightly during horizontal motion walking was eversion was only
TOEOFF
16 shows
patterns
aloimg greatly
HEELCONTACT
HEELCONTACT
TOEOFF
ANKLE ROTATION
_4. 10
SUBTALAR ROTATION
4FOOT
IMMOBILE+
O_
.4-FOOT
IMMOBILE
-+
(CI
ASCENT
OF SLOPE FIG.
Ib)
DESCENT
OF
SLOPE
18 slope walking
TOECONTACT
Ankle
TOECONTACT
and
,
subtalar
rotations
IIEELOFF
during
(subject
DGW).
IIEELOFF
RN
IO#{149}
4FOOT
IMMOBILE
=I
-__.__.________j__t..
(0)
SUBJECT
DGW FIG.
Ib) 19
SUBJECT
JM
Ankle
and
subtalar
rotations
during
backward
walking.
3.
Uphill
and
Downhill
were during the studied stance slope.
1Valking
walking phase, Since the up and down a ramp with was in dorsiflexion ascending orientation of both joint axes in this situation, be the same going rotations about presumably because in the iiext section. subject DGW did a 15-degree iiiand in plantar with respect to the net rotaup and going the aimkle axis of inactivity Subject J\i not.
dine.
flexion
the
tional
of progression
about
was essentially unchanged the axes were expected to in Figures 17 arid descent on the ramp, factor will be considered and ankle motion, while
down.
were
However,
18, the
of the showed
4. Backward
It
was
anticipated
backward
walking
THE
would
JOURNAL
produce
OF BONE
a revem-sal
AND JOINT
of the
SURGERY
ACTION
OF
THE
SUBTALAR
AND
ANKLE-JOINT
COMPLEX
377
imormal
subjects
displacements. walking
patterns patterns
two day
shown reversed in broken were very similar to the of ankle motion. time action of the Effect of Action
i\Iaxinmunm
It can be seen that the backward-walking normal patterns except for a much was presumably associated with
greater
patterns range of
elimination
walking. In or eliminated,
each of timese commditions, although the mechanism this pattern was heel rise, a subject
OFF
eversioim
indeed (WHH)
ANKLE
ROTATION
--.H
IO#{149}
+L
SUBTALAR
14
FOOT
IMMOBILE
ROTATION
N-.
_________ ]-
--------r-20 gait
__________________________
-
Fm;.
Ankle
9.11(1 subtalar
rotations
iim I)aralytic
(subject
\VHH).
of
time
leg
was
studied.
Time
only
functional
muscle 20) of
leg
was
a weak
were seen
tibialis excursion
in the
anterior.
and time
The
same
ankle
nearly
pattern
linear
here
(Fig.
showed
that
maximum
thmat
development
pattermms
just
mentioimed. be realized that time pattern of knee motion (and therefore and of ankle motion) was altered in this subject and may in backward walking, ramp walking, and sidehill walking. of tibia! also have The most surae also may
important
jim producing
associated
heel rise,
finding
but
imere was
altered
the
effect
of inactivity
of the
of the
other
triceps
rotational
patterns
joints
have Effect
on time amount
of ankle-joint
rotation.
for
rapid,
nornial,
and
slow
gait.
No
siglmificalmt S4thlalar
differences and
.1 nkle
Level
Walking ankle joints was nmeasured studies was used to deterTime degree of toeing-out on time unit was of time axes
duiiimg mine
assunmed
the raimge of motion in time subtalar and walking. The informatiomm gained iim previous factors
eaclm
2. MARCH
should was
ruim.
1964
affect
these and
eacim step
nmeasured
recorded
VOL.
46-A,
D.
G.
WRIGHT,
5.
M.
DESA!,
AND
W.
H.
HENDERSON
For
as not there
being was
walking. in the
subtalar pattern. Also not considered were steps in which there was premature heel rise as indicated by a negative deflection in the ankle patterns during time latter half of stance phase. Such steps were not taken into account because they produced a reduction steps with
In
rotation. Figure place in the first. listed in stance of the phase amount
21 shows of
two rotation
Table
measurements
subtalar
during
normal
FIG.
showing
early
DGW). been established as between second day of this study, his axis two
correction, assumed
5.5 degrees to the true longitudinal in adjusting the unit was similar on the was
6 degrees
and
the
average
ankle
rotation
Discussion Location
The system,
of Axes
testing fixed to unit the used foot and in these leg and studies adjusted can to best be described rotation as around a detector certain record
axes. The unit was first adjusted described in previous anatomical ences, further adjustments were The that objection the unit may rather be made than that the foot
to the positions of the ankle and subtalar axes studies 1,7,8#{149} Then, to allow for individual differmade until the subject had freedom of motion. the unit dictates is less the adaptable motions could of the than occurring the foot during and hence walking
and that lack of feeling of restriction by the wearer of the adaptability of the foot. However, in view to which made to the original allow freedom
be simply a manifestation careful anatomical studies adjustment and ankle that would
adjustment conformed and the final individual of movement, it is believed that the subtalar not significantly state. to Other positive
THE
different
from
those
Ankle
and
Subtalar foot
Rotations approaches
in heel
Relation strike,
Events rotation
JOURNAL
Cycle (Figs.
JOINT
As the
place
AND
8 and
SURGERY
ACTION
OF
THE
SUBTALAII
AND
ANKLE-JOINT
COMPLEX
379
TABLE
TAILE 3
-
III
MID AIIKI.E AXES
MEASUREMENTS
OP
ROTATIW4
ABOUT
of
SUBTALkR
DURING
NORMAL LEVEL
WALKING
11GW
deflection; 1 a. SECOND 0.8#{176} DAY
AX IS LOCATION
Ankle: horizontal,
0
AX IS LOCATION
102#{176}with
0
long with
&xi. long
Ankle:
horizontal,
0
990
wttm 12
long
Subtalar:
48
with
floor;
12
axis
Subtalar:
38
with
floor;
with
ANKLE
RIYEATION
SUBTALAR
ROTATION S 4
4 6 6
ANKLE ROTATION 14 11
13 18 19
SIIBTALAR 5 8
11 7 10
ROTATION
21 19
19 17 18
15
15 14 18 19
7
8 5 S 7
17
21 15 19 21
3
9 7
9
TOE
13 11 14
OUT
17
6 9 6 7 11 6 8 9 8 6 4 9 5 7 7 7
17 20 20 14 18 1 16 18 17 16 19 19 20 18 17 17
7 9 7
N
20
21 17 18 18 18 16 17 19 17 15 18 17 15 17
15
15 20 16 20 11, 18 18 12 14 14 18 15
10
5 8 8 5
12
10 12 13 10 10 13 13 7 10 9 Il 15 (5.8#{176}) 11.5#{176}
10 9 7 5 9 10 7 10 10 10 6 5
4
T 7 5 11 4 7 9 (12.6#{176})
Average
18 18 7 8 15 17 8 8
15.8
: 3
19
18 16 17 Is 20 18
A
6
8 9 10
13
14 16 19
8
8 7 6
6
13 8 1 (14.4#{176})
7
20
16 [6 1 (5 7#{176}) Average 21 17.2 (13.8#{176})
8
5
vera,c
18
7 7 5 (6.0
AIICLE
ROTATION:
14#{176}
AWLE
ROTATION:
14
SUBTALAR
ROTATION:
(corrected):
6 5.5
SUBTALAR
ROTATION:
6
TOE OUT
11). (1ig.
[he 3,F)
pretibial
are no
increasiimg
electrical
activity
first
during
timis
time
after
5
pei
heel
cent
strike,
of time
movement
imeutial.
1964
results
During
foot neutral
5 per
beiimg
cent
placed
of time
flat position
on time floor
time
with
8 to 10 degrees
aimd the
of time subtalar
pretibial
cycle,
2, MARCH
380
D.
G.
WRIGHT,
S.
M.
DESAI,
AND
\V.
H.
HENDERSON
muscles
show
their
peak
activity,
their
function
being
to
decelerate
this
motion
and thus prevent a slap of the foot on the floor. The small occurs in both patterns is possibly a rebound effect produced the shoe. At about 10 per cent of the cycle, positive rotation joint. graphic Our data methods are
(Fig.
the curve of ankle motion obtained by phototime 20 per cent of the cycle has been reached, full body extremity is moving weight is now beitmg is in swing pimase. forward over the
the ankle has rotated a few degrees past neutral. The carried by the extremity (Fig. 3,D) and the opposite
From 20 per cent
to 50 per
cent on the
of the ground
rotation
cycle,
the
body
foot,
time,
which
there
is immobilized
is progressive
positive
until at rotation
muscles
50 per at the
by body weight (Fig. 3,D). During this at both the ankle and the subtalar joint, direction. There is then sudden negative ceases at the subtalar joint. The posterior in a way analogous of the foot early rotation occurs this at the period of immobilization during the stance at the ankle During to that in stance ankle of the (Fig. phase. joint phase, joint foot.
3,D).
anterior
50 to
is
halt rotation muscles halt 65 per from cent the the of the ground, vertical
negative
heel per
lifted
As would
be expected,
to zero
cent of the cycle, the toe leaves the ground, ending the foot is in 6 to 8 degrees of negative rotation degrees returned tibia
from
of negative to neutral
rotation position.
at
the
subtalar
joint.
swing
One factor which has not yet been taken into account about its long axis. Figure 3,A is a curve representing highly variable data 2,9#{149} In general, it may be said that the tibia externally.
rotates internally, and during the remainder While the tibia rotates internally, there the subtalar rotation. joint ; and while the tibia This action will be discussed
naliy,
Analogy
of Universal
As previously
Joint
stated the ankle and subtalar joints act together to foot provide a between the so in a plane foot and the leg. As the that is not perpendicular dorsiflexes to the aimkle
is necessary about the subtalar as well as the ankle axis. is one feature of the action of the ankle and subtalar-joint made apparent by the simplified analogy of the universal joint to the axes of the universal joint, the ankle axis and the subtalar and are not mutually perpendicular. If a model of the system seen that flexion of the leg with respect to the shoe not oimly both axes but also requires tibia! rotation has been joint was used rotation of the experimentally to predict the action tibia about its observed (Fig. of the joint is
axis
is
requires rotation long axis. This 3,A). The analogy system motion flat ing, plane
It
universal
Figures segment
13 show that the subtalar phase in which the foot to toeing-out perpendicular rotation. ankle axis is exterimally
Thus, progressing from axis becomes progressively and noted as predicted from the shows anatomical
walkto the
progressively
JOURNAL
SURGERY
ACTION
OF
THE
SUI3TALAR
ANI)
ANKLE-JOINT
COMPLEX
381 as the
amount
toeimig-out.
position
rotatiomi,
It would
changed
be progressively
from toeing-ui to be seen
farther
normal
from
to
that
toeing-out.
perpendicular
The
walking
of ankle
then,
would
be expected that
were
to become the
progressively
less
duriimg
this
sequence.
In 1igures 14 degrees
subtalar
plotted
.
against
ankle-joint
the our
effect
of toeing-out
on the
ankle
joint
be too
small
to be
detected
positiomms
by
of
toeimg-out
oim ankle
of time
motion
metimods. Second, aimd toeing-in through the triceps deviated from of our analogy. that the pattern pattern walked
the muscle effort required may have exerted a selective surae. Third, with toeing-out, the parasagittal of ankle rotation plane for walked with and DGW
have
hence
in toeing-out
axis do
more the
nearly opposite.
rotation
than in inversion. This difference was the ankle obtained is inactive pattern
In our studies, mcre than had in eversion when the triceps in the limb with
ankle rotation been anticipated. was similar surae was the everted known foot
already
degree to the patterns Possibly, the triceps (Fig. l6,b) was at the kmmee had to go through of the
center been
higher level on the incline and the correspondimmg ankle a greater range of motion on this side to achieve effective and so
be
simortening have
must
extremity
It
prevent
concluded
excessive
that this
vertical
portion
oscillation
of the study
of the
would
of gravity.
must
done
with
the
feet
at equal
levels. amid everted Alteration knee may foot of the well have positions, rotational affected above and
Time
imave
of the tibia, produced the knee joint as well patterns of the suggested. in Figure produced that slightly the femur,
rotation as al ready Time subtalar patterns the neutral position patterns also show This is presumably perpeimdicular Time patterns
16 show
expected
displacenment
anticipated
to the obtained
down
a 15-degree
amid 18) simow the effect of time triceps ranmp, time foot was placed in an attitude axis
to
sum-ae on ankle rotation. In walking up the of slight positive rotation about the ankle amid this
Walking
at time onset
10 degrees
of as
of
of the
stance
stance
phase
phase
progressed.
positive
dowim
rotation
the
.JM
immcreased
ranip, when
by
the
only
energy
contl-ibutioim
the
to 30
triceps
degrees.
motion 1964
was
timan
ummecessary,
down
time Since
ankle JM had
i-otation motiomi
VOL. 46-A,
28
Imi walking
time ramp,
positive subtalar
aimd less
NO.
ankle
did
l)GW.
toeimmg-out
2, MARCH
382 walk,
It
D.
G.
WRIGHT,
5.
M.
DE5AI,
AND
W.
H.
HENDERSON
the
is
results
interesting
were
the motion
ramp allows
triceps In
was the
surae.
entirely foot to
absent be
efficient
contraction
an attempt to minimize the effect of muscle action, tracings were made as the subjects walked backward (Fig. 19). These patterns were similar to the reversed normal patterns for the same subjects, except that the ankle patterns showed the increased rotation associated with absence of action of the triceps surae. The pat-
if reversed, more
one
would and
most
to those motion
arguments
down
They
subtalar
of the
as compared
ascribing a
convincing
universal-joint with
rotation. negative
type positive
For every
of action rotation
negative
to the of the
rotation
subtalar ankle
and joint,
system. joint
During shows
stance, positive
every
rotation. to
in
If The
the
of the ankle joint, records are examined, is that in the other. of walking or uphill the joints
seen
tion joints
coincide. one
implication
is required,
Normal
Range
of Subtalar
Ankle
for one
Motion
was subject or made to during toeing-out determine level the walking. position normal The of the range preceding foot and whereas to be in the rethat of
In the
subtalar sections
action
final
ankle
study, motion
an that
attempt
and had
of the
established
a toeing-in
significantly altered length, and extent axis was measured the anatomical studies.
subtalar and ankle motion, of arm swing did not. from the unit and was seen the and only laxity subtalar 14 degrees but
14
general
The average values for motion about subject in stance phase were 6 degrees The value over joint may ankle joint of 6 degrees the same contributes the after appears period was significantly progressive fusion. ankle motion the subtalar This fact
in the
spectively.
to be small,
it is realized
explain
subtalar
Conclusions
It is concluded
that between
the the
but joints
role
iii
the
stance
of mmormal
believed
interdependent
respectively,
one
References
1.
2.
BARNErF,
C. H.,
and
NAPIER, OF,
fluence
Human
thel
Project,
upon
Advisory
June
the Form
UNIVERSITY
of the Talus
Other
on
CALIFORNIA,
Locomotion
and
Axis of Rotation of the Ankle Joint in Man. Its Inof the Fibula. J. Anat., 86 : 1-9, 1952. Devices Research Project: Fundamental Studies of Relating to Design of Artificial Limbs. [Report to
National 464)
JOURNAL OF BONE AND JOINT SURGERY
Committee 1947.
Research
Council.
Berkeley,
The
on page
THE
464
patients. cent; decrease der and flexion of arm made Shoulder at flexion
PROCEEDINGS
had
16 per was found
decreased
cent; to and
an average
extension approximately Arm-length
the
in
elbow,
of
abduction,
28 per
The normal
with the right
sigimificalmt.
force
shoulRoent-
be
right-handed
patients.
discrepancies
genograms
The
greatest
an average
2.2 centimeters.
loss of length
The longer
of 1.5 centimeters
after operation, the effect
exercises
arm-length
difference.
The author
thoracotomy on
suggested
the strength
that
additional
of the arm.
studies
After
need to be made,
this procedure,
such as
endurance
of left
proved
ditional
weaknesses
with
therapy
the right.
of multiple
patients with
H. MOON
mustard
discussed
treat
in
a current
fourteen
myeloma
multiple
to
consecutive
he at
used the or
The criteria for judging results were: ( 1 ) improvement the amount of abnormal protein in the serum or urine, bone lesions, or both, (4) decrease in the amoummt of plasma
resistance to significant claimed for infection, degree urethane. and (6) survival. which This series In
of
(5)
compared
increased
of ulmselected of is is
with
achieved
a published
some
series
in regard
to the response
Although
rate.
cent
of palliation,
than the 20 per cent remission rate not the complete answer to the therapy currently available.
DR. EDWIN
1-phenylalanine
of multiple
myeloma,
it seems
to he the
that
M.
HAKALA of
20
discussed
Richmond,
the problems
Virginia.
of
fitting
prostheses
in
juvenile
amputees.
19. 20.
Virginia,
Richmond,
Avenue,
Virginia.
REFERENCES AevIoN
OF THE SUBTALAR AND ANKLE-JOINT COMPLEX DURING STANCE PHASE OF \SALKING
(Continued 3.
CALIFORNIA, Activity to thel in the Advisory UNIVERSITY OF, Prosthetic
from
Devices
page
38)
Project:
Research
The
Pattern
Lower
Extremity
on
During
Artificial
Walking.
Limbs,
A Presentation
National Research
of Summarized
Council.
Committee
25, September 1953. 4. CLOSE, J. R., and INMAN, V. T.: The mittee on Artificial Limbs, National
University of
5. CLOSE,
Committee Project,
J. It.,
S.
Action of the Ankle Joint. [Report to thel Advisory ComResearch Council. Prosthetic Devices Research Project, Berkeley, Series 11, Issue 22, April 1952. V. T.: The Action of the Subtalar Joint. [Report to timej Advisor?
National Berkeley,
on University
6. DESAI,
mechanics No. 45. 7.
W.
H. :
Council.
Prosthetic
1)evices
Researc
1 1, Issue
Design
24, 1ay
of
University
of California,
San
Francisco
and
8.
9.
HICKs, MANTER,
397-410,
RYKER,
J. H.: The Mechanics of the Foot: I. The Joints. J. Anat., 87 : 345-357, 1953. J. T. : Movements of the Subtalar and Transverse Tarsal Joints. Anat. Rec., 80: 1941. N. J., JR.: Glass Walkway Studies of Normal Subjects During Normal Level Walking.
to
[Report
thel
Advisory
Committee
on
Artificial
Limbs,
National
Research
Council.
Prosthetic
Devices
Research
Project,
University
of California,
Berkeley,
Series
1 1, Issue
20,
January
1952.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY