01964011/87/0901-0003$02.

00/0 THEJOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright 0 1987 by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association

Locomotor Biomechanics and Pathomechanics: A Review

LARRY P. BROWN, MA, PT, ATC,* PATRICIA YAVORSKY, BS, P T t This review is intended to provide a working knowledge of clinical anatomy and arthrokinematics of the foot and ankle. Primary functions of the foot, the gait cycle, and pathomechanics will also be discussed. Emphasis is placed on basic biomechanical considerations which form the basis for both static and dynamic evaluations. Also presented are some of the most commonly seen osseous deformities contributing to pathomechanics.

Locomotion is the process or ability by which man moves himself from one geographic location to another.'' Biomechanics defined at face value is made up of two roots, bio and mechanic^.^' "Bio" indicates a relationship to life, living tissue, or organisms.24"Mechanics" is a physical science dealing with the state of bodies and the action of forces.20Therefore, locomotor biomechanics pertains to the study of forces and the effects of those forces on and within the human body while moving from one position to another. Familiarity with the biomechanics of walking is a prerequisite for an appreciation of the biomechanics of running since the same basic mechanics are present in both gaits. To further appreciate the various types of pathomechanics seen in the runner, a good working knowledge of normal locomotor biomechanics is necessary. This allows the practitioner to identify abnormal biomechanics present during running so that treatment can be based on a firm scientific basis rather than on an empirical one.14 To support this statement, this article will include discussions on basic arthrokinematics of the foot and ankle, primary functions of the foot, review of the gait cycles, and pathomechanics.
Arthrokinematics Ankle

gruency of the ankle mortise is maintained by the strong ligamentous system, the capsule, the interosseous ligament, and the various tendons and retinacula about the joint. Functioning primarily as a hinge joint, it allows for motion in 1'of freedom, the sagittal plane. These movements are typically referred to dorsiflexion and plantarflexion. However, the axis of rotation is described as passing laterally through the talus and slightly inferoposteriorly on the transverse plane.'* Since this axis is not exactly perpendicular to the sagittal plane, slight motions of abduction and eversion accompany dorsiflexion, and adduction and inversion accompany plantarflexion. Most authors report that functional range of motion for the ankle is on the order of 10-20' of dorsiflexion and 20-30' of plantarfle~ion.~-'~~'~ When these movements become extreme, the subtalar joint and midtarsal joints contribute to the range of motion of the ankle joint.
Subtalar Joint

The ankle joint is composed of three joints: the tibiotalar, fibulotalar, and tibiofibular. The con* Director. Palo Alto Physical Therapy and Sports Injury Center. 913 Emerson Street, Palo Alto. CA 94301. t Director, La Jolla Sports Therapy

The subtalar joint is the articulation between the inferior surface of the talus and the superior surface of the calcaneus. This articulation occurs at two separate articular facets, a posterior facet where the inferior concave surface of the talus rests on the superior convex surface of the calcaneus, and an anterior facet with a convex talar facet fitting into the concave calcaneal surface. These facet surfaces are united by powerful ligaments that withstand the stress of locomotion. The reported axis of rotation is 41-45' from the horizontal in the sagittal plane and 16-23' medially, when measured from a longitudinal axis pass3

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ing through the midcalcaneus in the transverse plane.4~9~'0~'2~15 This oblique single axis is oriented from a posterior, lateral, inferior position, to an anterior, medial, superior position.13 The oblique orientation of the axis causes it to traverse the three cardinal planes, thus movement about this axis will occur in all three planes. The term used to describe this type of movement is "triplanar motion." Manter15describes the overall movement of the subtalar joint as a combination of eversion, abduction, and slight dorsiflexion of the foot. This combined triplanar movement is simply termed "pronation." The combined movements of inversion, adduction, and slight plantarflexion are termed "supination." The amount of subtalar joint range of motion reported is controversial; however, most authors agree that the amount of inversion as a component of supination is significantly greater than eversion as a component of pronation when the foot is free.l4 The -normal functional range of motion seen in walking is between 6 and 1 0 ' of motion equally divided by a neutral position of the subtalar joint. The neutral subtalar position as described by Root et aI.l7 is that position from which the subtalar joint can be maximally pronated and supinated, or when the subtalar joint is neither pronated nor supinated.
Midtarsal Joint

dent of each other, but both depend on the position of the subtalar joint. When the calcaneus is in an everted position, the subtalar joint is pronated and the planes of the axes between the talonavicular and calcaneocuboid joints become parallel. This results in increased midtarsal joint motion by "unlocking" the j ~ i n t . ' ~Conversely, ~*~ when the calcaneus is inverted, the axes are no longer parallel, and there is decreased motion of the midtarsal joint due to the convergence of the axes. This convergence "locks" the bones of the midtarsal joint creating a rigid forefoot. The mobility created during rearfoot pronation and the rigidity created during supination play a major role in the primary functions of the foot.
Other Functional Joints

The midtarsal joint or transverse tarsal joint consists of the talonavicular joint medially and the calcaneocuboid joint laterally. Two separate rotational movements with distinct axes are described by Manter.15 Both axes are positioned obliquely to the cardinal planes; thus, they exhibit triplanar motion. The longitudinal axis of the midtarsal joint is directed anteriorly and superiorly 1 5 ' from the horizontal plane, and medially di' from the longitudinal plane. It allows rected 9 pivotal movements of the cuboid on the calcaneus. The axis passes between the first and second rays, and allows motion of inversionladduction and eversion/abduction of the cuboid. The oblique axis of the midtarsal joint is directed anteriorly and superiorly 5 2 ' from the horizontal plane, and medially 5 7 ' from the longitudinal plane. The major actions about this axis are dorsiflexion/abduction, and plantarflexion/adduction of the forefoot. Though the description of the midtarsal joint appears complex, the biomechanical function can be greatly simplified by recognizing that motion perpendicular to the two axes may be indepen-

The first ray is a functional metatarsal unit consisting of the first metatarsal and the first cuneiform bones. The first metatarsallfirst cuneiform joint, and the first cuneiform navicular joint move together about a common axis of m ~ t i o nThe .~ axis passes anteriorly, laterally, and plantarly 5 ' angle from the frontal through the foot at a 4 and sagittal planes. This axis produces the triplanar motions of dorsiflexion/inversion, and plantarflexion/eversion. The second, third, and fourth r&s are formed by the articulations of the metatarsals with the appropriate cuneiforms. Each of these rays appears to exhibit pure sagittal plane motion. The fifth ray consists of the fifth metatarsal only. The axis of motion lies at an angle of approximately 2 0 ' from the transverse plane and 3 5 ' from the sagittal plane. Therefore, it has a triplanar axis allowing movement in the directions of supination and pronation. The first metatarsophalangealjoint consists of the articular surface of the first metatarsal head and the base of the proximal phalanx of the hallux. It has two distinct axes of motion, a transverse axis and a vertical axis. Pure plantarflexion and dorsiflexion are provided by the transverse plane and pure adduction/abduction are provided by the vertical plane.'*
PRIMARY FUNCTIONS OF THE FOOT DURING LOCOMOTION

The joints of the foot perform two primary functions during the stance phase of gait; they allow the foot to interface with the ground and they provide a base over which the body can be pro-

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pelled.' During ground interface at heel strike, the foot becomes a mobile adapter. This allows accommodation to terrain variances and postural deviations of the trunk, and assists in providing shock absorption. Shock absorption is a necessity since impact stress at heel strike may exceed body weight and may be increased to three times body weight during running.14 Locking of the major joints of the foot transforms the foot into a rigid lever. This is necessary for normal propulsion during the late stance phase of gait. These functions are accomplished by the joints of the foot and ankle through the combined actions and motions of the subtalar and midtarsal joints during pronation and supination.
GAIT CYCLE

The gait cycle is used as the basic reference in the description of locomotion. This makes it possible to compare walking and running very easily. One full gait cycle is the interval of time from heel strike of one foot to heel strike by the same foot at the next Therefore, there are two steps in each gait cycle. During the gait cycle, motion occurs in both open and closed chains. Open chain motion occurs when the distal component is not,fixed and the muscle contraction is concentric. Closed chain motion occurs when the distal component is fixed and muscle contraction is eccentric. The gait cycle is divided into two phases, the stance phase and swing phase. Closed chain motion occurs during the stance phase and open chain motion occurs during the swing phase. The stance phase is that period which begins with heel contact and ends with toeoff. The swing phase occurs between toe-off and heel strike. In normal walking, the stance phase consists of approximately 60% of the gait cycle, 14,17.18 and the swing phase approximately 40o O / Since one complete cycle takes approximately 1 sec to complete, and 60% of the cycle consists of the stance phase, the foot is on the ground for approximately 0.6 sec during ~ a l k i n g . ~ To facilitate clinical observations of the lower extremity during locomotion, the stance phase of gait is divided into three periods, contact, midstance, and propulsion.
Contact

27% of the total stance phase and is characterized by hip joint extension and internal rotation, knee flexion, lower leg internal rotation, ankle plantarflexion, and subtalar joint and forefoot pronation. The lower leg and foot are viewed as functional units, the talus and lower leg function as one unit, the calcaneus and foot as another. With closed chain motion, during the stance phase of gait, the talus moves in the same direction as the lower leg, and the foot follows the calcaneus. At heel strike, the leg is externally rotated so the subtalar joint and forefoot are supinated. The initial supinated position results from the contraction of the dorsiflexors and inverters of the ankle as they prepare to decelerate plantarflexion and pronation during contact. Controlled pronation occurs, helping with shock absorbancy. A normal foot does not pronate beyond the contact period, and reaches its maximally pronated position at the end of contact (Fig. 1A). The calcaneus is everted from neutral by approximately 4-6O at this point.l4*l8
Midstance

Contact begins with heel strike and ends as the forefoot becomes fully weight borne with the entire foot flat on the ground. Contact accounts for

Midstance follows contact and is characterized by single limb support in normal walking. It consists of the intermediate 40% of stance phase. The primary event occurring during this period is the conversion of the foot from a mobile adapter ~ ~ ' is ~ ac~~~~~~ to a rigid lever for p r o p ~ l s i o n . This complished as the lower leg begins to externally rotate, and closed chain supination occurs at the subtalar joint. The talus abducts and dorsiflexes on the calcaneus while the calcaneus inverts. During the first part of midstance, the subtalar joint is supinating as the rearfoot moves from a maximally pronated position back toward a neutral position just prior to heel lift. During the remaining midstance period, the subtalar joint continues to supinate and the rearfoot moves into a supinated position. When the neutral subtalar joint position is reached, the midtarsal joint locks up against the rearfoot. A rigid forefoot is produced in preparation for propulsion. This rigid state is important to allow for the various tendons of the leg to function around stable bony levers. During this phase of gait, the trunk and lower leg move forward, and the ankle is required to dorsiflex to 10'. The knee begins to extend as the hip continues its extension from the initial contact phase.

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Tibia#

F b i;

--

-+I I I

---

--0

Talus
Calcaneous

Fig. 1 . Normal subtalar joint motion and the neutral foot. A, At heelstrike (HS) the subtalar joint is slightly supinated. Normal pronation occurs through contact to foofflat (FF). At midstance, supination begins so that just prior to heel rise (HR), the subtalar joint is in neutral position. Supination continues through toe-off (TO). The neutral foot and lower leg is illustrated in this figure in compliance with the criteria of normalcy.

Propulsion The final 33% of the stance phase of gait is the propulsive portion which begins with heel lift and ends with toe-off. The body weight is shifted from the lateral side of the foot to the medial side and to the great toe. This is accomplished by continued closed chain supination at the subtalar joint as the leg continues to externally rotate. This increases the skeletal efficiency of the foot as it continues to function as a rigid lever. The ankle moves from its terminally dorsiflexed position of 10 to its terminally plantarflexed position of 20. The knee rapidly flexes and the hip continues to externally rotate and flex. The final phase of propulsion requires the first metatarsophalangeal joint to be stabilized, enabling it to dorsiflex approximately 70 as the weight is being transferred from the first ray to the great toe, and finally to the opposite foot. CHANGES WHICH OCCUR IN RUNNING GAIT Running gait differs from normal ambulation in that there is an airborne float phase when neither foot is in contact with the ground. This produces two primary changes in the running gait: an increased magnitude of the vertical ground reaction forces and a progressive shortening of the stance phase of gait.79 14.17318321 As the speed of gait increases, the vertical ground reaction forces increase from 70-80% of body weight during walking to approximately 275-300% during running.14 This occurs as a

result of Newton's third law: for every action there is an equal and opposite reaction. Other ground reaction forces such as fore and aft shear, medial and lateral shear, and torque demonstrate essentially the same patterns for walking and running gait, but the magnitudes of these forces increase somewhat with r ~ n n i n g . ~ , ' ~ As the speed of gait increases, there is a progressive decrease of total stance time from 0.6 sec during walking to 0.2 sec during running. Therefore, all events which normally occur during stance must occur approximately three times faster in running than in walking. This marked decrease in stance phase and the marked increase in ground reaction forces are the primary reasons given for injuries to runners.21 CRITERIA FOR NORMALCY A normal lower leg and foot is one which, during locomotion, places no undue stress upon itself or the proximal joint^.^' The criteria for normalcy, described below, represent the ideal physical relationship of osseous segments of the foot and leg which should be present for maximum efficiency during loc~motion.'~ Seldom seen clinically, these relationships represent a basis for evaluation of the degree of deformity present. Once the criteria for normalcy are evaluated, any deviation from one criterion constitutes deformity or abnormality.' The criteria for normalcy are as follows: the distal one-third of the lower leg is vertical or in the sagittal plane; the subtalar, ankle, and knee joints lie in the transverse plane parallel to the ground;

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the subtalar joint is in its neutral position, neither pronated nor supinated; bisection of the posterior surface of the calcaneus is vertical or inverted no more than 3-4" from the vertical; the midtarsal joint is locked in its maximum position of pronation; the metatarsals and plantar surface of the calcaneus lie parallel to each other in the transverse plane; and last, there are no rotational or torsional influences present in the lower leg. Figure 1B illustrates this ideal physical relationship. During locomotion, all normal criteria should be present just prior to heel lift. Deviations from normalcy in the biomechanical system may cause abnormal motion and stress to occur during the stance phase of gait. This may, in turn, be manifested in the form of a stress injury.'
PATHOMECHANICS

As defined previously, locomotor biomechanics is the application of mechanical laws to living systems in motion. Pathomechanics can then be defined as the mechanics of living systems in motion resulting in, or leading to, dysfunction or injury. The remainder of this article is devoted to the pathomechanics of the ankle and foot including common intrinsic abnormalities, resultant pathological states, and treatment options. In order to understand the pathomechanics of the ankle and foot, one must first understand the concept of compensation. Compensation is defined by Root et al.'' as a change of structure, Subtalar Varus position, or function of one part of the body in an attempt to adjust to a deviation of structure, Subtalar varus, as illustrated in Figure 2A, is an position, or function of another body part. More inversion deformity of the calcaneus due to an basically stated, compensation is the counterbalincomplete derotation of the posterior calcaneus ancing of any defect in structure or f~nction.~ from its'infantile position.'' In childhood, the calThere are two types of compensation, normal and caneus derotates 3-4". If this derotation is incomabnormal. Normal compensation maintains balplete or does not occur, subtalar varus reance and produces no abnormality or pathology. s u l t ~ . ~ .Compensation ~~'' for this deformity during An example of normal compensation is the adlocomotion requires calcaneal eversion to vertical aptation of the foot to variations in surface terrain. at heel strike in order for the condyles of the Abnormal compensation is an adjustment for abcalcaneus to reach the ground. The foot remains normal structure or function of the body which, partially pronated at heel lift not allowing the subupon repetitive demand, may lead to pathology. talar joint to supinate to neutral in early propulsion. In the foot, both types of compensation, normal The first ray is not adequately stabilized by the and abnormal, result from pronation and supinaperoneus longus muscle and hypermobility is tion of the subtalar and midtarsal joints. When present. Increasedload and shear forces are presbony or soft tissue deformities of the foot or lower Once ent beneath the second metatarsal headT8. extremities are present, abnormal compensatory the heel is off the ground, the normal forefoot pronation or supination may result. Each is dissupinates in an attempt to become a rigid lever. cussed below. Abnormal compensatory pronation occurs only Pronation is considered abnormal when it is in during the time the abnormal calcaneus is in excess of the amount required, or when it occurs ground contact (Fig. 28).

when supination should be occurring during locomotion.18 Normal minimum pronation required during walking locomotion has been shown to be 6", with maximum values averaging 9.4" and a standard deviation of 3.5.3,'8,21Excessive pronation can then be defined as 13" or greater. According to S~botnick,~' the most common cause of foot pathology is abnormal compensatory pronation because the foot is abnormally unstable in a weightbearing situation. This leads to hypermobility, subluxation, resultant microtrauma, and Causes of abnormal compensatory pronation can be intrinsic or extrinsic to the foot. This paper focuses only on the intrinsic causes. They include subtalar varus, forefoot varus, forefoot supinatus, forefoot valgus, and ankle joint equinus. Abnormal supination is excessive supination, or supination that occurs when pronation should be occurring during normal gait. Normal values for supination have been shown to range from 612.'8,21 Compensation for a forefoot valgus, plantarflexed first ray, or equinus deformity can cause abnormal supination. Pathology may also occur when motion is restricted or when it is insufficient for normal locomotion. Disease, trauma, contracture, or congenital coalition may be some causes of these problems. The following are descriptions of common intrinsic abnormalities of the foot.

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Fig. 2. Subtalar varus. A, Subtalar varus deformity is illustrated as seen when in the subtalar joint neutral position. It is an inversion osseous deformity of the calcaneus in the neutral position. 8,Abnormal compensatory pronation begins at heel-strike (HS) and continues until heelrise (HR) when the abnormal calcaneus is no longer in contact with the ground. The foot supinates late after heelrise (HR) in time for propulsion to be fairly normal. (Abnormal cycle shown in broken line.)

Abnormal compensatory pronation for a subtalar varus may result in pathology. Plantar keratoses beneath the second metatarsal head may develop due to increased shear, inflammation, and hyperplasia. Soft tissue lesions may also develop such as peroneus longus tendinitis due to insufficient first ray stabilization, posterior tibialis tendinitis due to excessive deceleration of pronation, or Achilles tendinitis due to excessive active supination. Articular lesions may develop at the patellofemoral joint due to the antagonistic state of maximum pronation and maximum knee flexion not occurring sim~ltaneously.'~'~~~~
Forefoot Varus

Forefoot varus, as illustrated in Figure 3A, is a fixed congenital osseous deformity of the forefoot in which the plane of the lesser metatarsals is inverted in relation to the calcaneus in subtalar joint neutral position. Forefoot varus is caused by a failure of the head and neck of the talus to fully derotate from the infantile p o ~ i t i o n . ~It .'~ is the most common cause of abnormal compensatory pr~nation.~~ The pathomechanics of compensated forefoot varus are much more destructive than subtalar varus. Once the condyles of the calcaneus are on the ground, the subtalar joint must continue to pronate in order for the first ray to reach the ground. The calcaneus then everts past the neutral position and at heel rise, the foot is in maximum pronation. The forefoot remains in pronation throughout propulsion resulting in severe instabil-

ity. The first ray is hypermobile and the second metatarsal takes most of the force during propulsion. Figure 3B illustrates how abnormal compensatory pronation occurs throughout stance and propulsion in a compensated forefoot varus. This results in more destructive pathologies in the soft tissues and bony tissues mentioned previously with subtalar varus. The pronated position of the forefoot during propulsion can also lead to forefoot pathology. Predisposing factors to the development of forefoot pathology are the amount of first ray hypermobility and the congenital angulation of the longitudinal axis of the metatarsals to the rearfoot." Hypermobility of the first ray during propulsion results from the inability of the peroneus longus to stabilize sufficiently. Hypermobility can lead to subluxation of the first metatarsophalangeal joint. Subluxation in the transverse plane can result in hallux-abductovalgus (HAV) deformity,8918 Subluxation in the sagittal plane can result in hallux limitus deformity. The determining factor in the development of HAV or hallux limitus is the congenital angulation of the forefoot to rearfoot. The more adducted the forefoot, the more likely a HAV is to develop. Conversely, a more rectus forefoot would more likely lead to a hallux limitus.18 Forefoot supinatus is a reducible, acquired soft tissue contracture at the midtarsal joint resulting in supination of the forefoot.' Supination contracture may occur about either the oblique or longi-

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LOCOMOTOR BIOMECHANICS AND PATHOMECHANICS

Fig. 3. Forefoot varus. A, Forefoot varus is an osseous deformity of the talus in which the forefoot is inverted relative to the calcaneus in subtalar joint neutral position. 6, In order to get the inverted forefoot to the ground, abnormal compensatory pronation occurs. Pronation is excessive and continues from foofflat (FF) throughout the stance phase of gait into propulsion. (Abnormal cycle shown in broken line.)

tudinal axis of the midtarsal joint. Forefoot supinatus about the oblique axis results in forefoot adduction, plantarflexion, and slight inversion. Clawing of the toes may result from the transverse plane instability caused by the relatively abducted position of the phalanges to the metatarsals in oblique axis forefoot supinatus. Supinatus about the longitudinal axis is difficult to differentiatefrom forefoot varus. However, it is attributed to contracture or spasm of the anterior tibialis muscle resulting in dorsiflexion of the first ray and forefoot supination rather than talar pathology seen in forefoot varus. Abnormal compensatory pronation is the result of either forefoot supinatus and resultant pathologies including those previously mentioned for subtalar and forefoot varus.18
Forefoot Valgus

Abnormal supination occurring during midstance can lead to pathologies related to lack of shock absorption in the upper leg, but also to development of plantar lesions beneath the fifth and first metatarsals. Abnormal pronation occurring late in propulsion can lead to hallux subluxations previously discussed for forefoot v a r ~ s . ~ ~ ' ~
Equinus

Forefoot valgus, as illustrated in Figure 4A, is an osseous deformity of the forefoot in which the plane of the lesser metatarsals is everted relative to the calcaneus in subtalar joint neutral position18 Heel strike is normal with forefoot valgus, but the forefoot is prematurely loaded. The first ray is stable, and abnormal compensatory supination CONCLUSION occurs at the subtalar joint resulting in absence of normal pronation during midstance and late Ankle and foot biomechanical abnormalities pronation at heel-off to allow knee f l e ~ i o n . ~ , ' ~ may occur independently or in combination. An Forefoot valgus can take the form of a plantarunderstanding of normal and abnormal locomotor flexed first ray or a total forefoot valgus. Figure biomechanics is essential for effective patient 4 8 illustrates the absence of normal pronation care. Once normal mechanics are understood, during stance with forefoot valgus as well as late pathomechanicscan be identified and the etiology abnormal compensatory pronation. of patient complaints postulated. It is necessary

Ankle equinus is a fixed limitation of dorsiflexion at the ankle joint to less than 10' when in the subtalar neutral position and with the knee extended.'' Compensation takes place at the subtalar and midtarsal joints in the form of abnormal pronation allowing dorsiflexion of the forefoot on the rearfoot. Abnormal pronation is present during propulsion resulting in hypermobility of the first ray. Resultant pathologies are those noted previously for abnormal pronation occurring through propulsion including keratoses and hallux deformities, but symptoms seem to occur earlier in life and are resistant to conservative management.10,22923

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Fig. 4. Forefoot valgus. A, Forefoot valgus is an osseous deformity of the forefoot in which the forefoot is everted relative to the calcaneus in subtalar joint neutral position. 6, Abnormal supination occurs as the forefoot is prematurely loaded after heelstrike (HS). Pronation is insufficient, then occurs late in stance at heel-off (HO) to allow knee flexion. (Abnormal cycle shown in broken line.)

to treat not only the symptoms but also the cause of the dysfunction. A comprehensive treatment regimen must include a thorough biomechanical evaluation, appropriate for pain and therapeutic exercise to restore normal length/ strength/function of musculature, and exercises Or-P enhance P ~ ~ thotic devices to correct biomechanical abnormalities may be indicated to help decrease abnormal compensation. Early identification of biomechanical dysfunction and proper intervenfor and decreased likelihood for recurrence of injury in the future.
REFERENCES
1. Bates BT, Ostemig LR, Mason JR, James SL: Functionalvariability of the lower extremity during the support phase of running. Med Sci Sports Exerc 11:328-331,1979 2. Calliet R: Foot and Ankle Pain. Philadelphia: FA Davis Co, 1968 3. ClarkeTE, Frederick EC, Hamill C: The study of rearfoot movement in running, In: Frederick EC (&), Sports Shoes and Playing Surfaces, Ch 10, pp 116-189. Champaign, IL: Human Kinetics Pub lishers Inc. 1984 4. Close JR, lnrnan VT. Poor PM, Todd BA: The function of the subtalar joint. Clin Orthop 50:159-179. 1967 5. Dorland's Illustrated Medical Dictionary, ED 25, p 345. Philadelphia: WB Saunders Co, 1974 6. Ebisui JM: The first ray axis and the joint. J Am Podiatry Assoc 58:160-168,1968 7. Gray G: When The Feet Hit the Ground, Everything Changes. Toledo: American Physical RehabilitationNetwork, 1984

8. Hlavac H: compensated forefoot varus. J Am Podiatry Assoc 60:229-233.1970 9. lnrnan VT: The human foot. Manitoba Med Rev 46:513-515,1966 lo. Inman vr, Mann RA: Biomechanicsof the foot and ankle. In: Mann RA (ed), DeVries Surgery of the Foot, c h 1, pp 3-21. s t Louis: cv Mosby Co, 1978 11. Inman , , Ralston HJ, Todd F: Human Walking. Baltimore: Williams 8 Wilkins, 1981 12. Isman RE, lnrnan VT: Anthropometric studies of the human foot and ankle. Bull Prosthet Res 97:76, 1969 ~ JA: The Physiology ~ of the Joints, ~ Val 2. New Yo*: ~ 13. Kapandji churchill-~ivingstone, 1970 14. Mann RA: Biomechanics of running. In: Mock RP (ed), Symposium on the Foot and Leg in Running Sports, pp 1-29, St Louis: CV Mosby Co, 1982 15. Manter JT: Movements of the subtalar and transversetarsal joints. Anat Rec 80:397,1941 16. Mumy MP, Drought AB. Kory RC: Walking patterns of nonnal men. J Bone Joint Surg (Am) 46:335-344,1964 17. Root ML, Orien WP, Weed JH: Biomechanical Examination of the Foot. LOS Angeles: Clinical Biomechanics Corporation, 1971 18. Root ML, Orien WP, Weed JH: Normal and Abnormal Function of the Foot. Los Angeles: Clinical Biomechanics Corporation, 1971 19. Sammarco GJ, Burstein AH, Frankel VH: Biomechanics of the ankle: a kinematic study. Orthop Clin North Am 4:75-83, 1973 20. Smidt GL: Biomechanics and physical therapy: a Perspective. Phys Ther 64:1807-1808,1984 21. Subotnick SI: Biomechanics of the subtalar and midtarsaljoints. J Am Podiatry Assoc 65:756-764, 1975 22. Subotnick SI: The biomechanics of running: implications for the preventionof foot injuries. Sports Med 2:144-153, 1985 23. Subotnick, SI: The flat foot. Phys Sports Med 9:85-91, 1981 24. Taber CW: Taber's Cyclopedic Medical Dictionary, Ed 14, pp 179. Philadelphia: FA Davis Co, 1977