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Lateral STJ axis feet that look as though they are pronating

Discussion in 'Biomechanics, Sports and Foot orthoses' started by bigtoe, Mar 4, 2010.

  1. bigtoe

    bigtoe Active Member


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    Hello all

    I have been recently getting confused by what I appearing to be seeing, I will try to explain-

    symptons- medial knee pain, LBP and ankle instability.

    genu valgum knees
    lateral STJ axis
    plantarflex 1st ray
    low gear foot type
    low/medium supination resistance
    low/medium Jacks test
    lots of lateral wear in shoes
    hypermobilty?
    reduced ankle dorsiflexion

    static assessment- what appears to be the rearfoot sitting in a pronated position although medial arch high.

    gait assessment- what appears to be medial heel strike with midstance supination



    what is throwing me is- shoe has lateral wear, STJ axis is lateral so why do I appear to be seeing a foot that is pronating, at the moment i think it may have something to do with hypermobility and internal rotation force due to genu valgum.

    my main question is why do i appear to be seeing a pronated foot when the STJ axis is lateral???

    cheers in advance

    Scott
     
  2. efuller

    efuller MVP

    Scott,
    Is this a single foot or a composite picture from a group of feet.

    In some feet with laterally positioned STJ axes there is some paradoxical pronation of the STJ. Ground reaction force will tend to cause more supination, or less pronation, in feet with laterally positioned axes. However, people don't like to have there feet oversupinate when walking and in response they will use their peroneal muscles to create a larger pronation moment than the supination moment from the Achilles tendon and the ground. This will create a late stance phase pronation.

    Regarding lateral shoe wear. There are some feet with laterally positioned axes that can stand with relaxed muscles. There are other feet with more extremely laterally positioned axes that have to constantly contract their peroneal muscles to keep the foot plantigrade (prevent rolling into max supination). For those feet that can stand with relaxed muscles the center of pressure under the foot must be directly beneath the STJ axis. To maintain equilibrium, the moment from the forces on the lateral side of the axis have to equal the moment from the forces on the medial side of the STJ axis. When the axis is latterally positioned, the distance will be small on the lateral side of the axis. So, when the distance is small the forces have to be higher (moment = force times distance). These feet are interesting in that when you try to put your fingers under the lateral forefoot, your fingers get crushed. Yet, when you ask them to evert they have a lot of eversion range of motion available. (This is in contrast to the uncompensated, partly compensated varus foot that will crush your fingers under the lateral forefoot, but have no eversion range of motion available. Think Coleman block test.)

    Finally, there are some rare feet that are very floppy looking that have laterally positioned STJ axes. Most of the time, you can look at arch height and make a pretty good guess as to where the STJ axis is. However, there are exceptions, so you do have to assess axis position and not just go by how the foot looks.

    Regards,

    Eric
     
  3. bigtoe

    bigtoe Active Member

    cheers for the reply Eric

    "Is this a single foot or a composite picture from a group of feet."

    its just a loose example of a group of feet i now appear to be seeing on a weekly basis.

    i think what you are saying makes sense, i am trying at the moment to take it all in, when i come across these feet up till now i have been trying to post on the lateral side of the axis to increase the force to try and reduce the supination moment. i am trying to programme my brain into not reading to much into the static pronated appearance.

    cheers

    scott
     
  4. Scott,
    Try posting to reduce the stress on the target tissue. Remember to think in 4-dimensions: it is quite possible to have a foot in which the STJ axis which is medially deviated at one point in time during the contact period and laterally deviated at another. Indeed, you may see significant shift in axial position from barefoot standing to shod walking. The axial excursion during dynamic function is key. Identify which tissue is under stress and when; then work out the biomechanical function of that tissue at that time. If you understand how foot orthoses work, you can then tailor your prescription appropriately.
     
  5. P.S. axes don't determine motion...
     
  6. bigtoe

    bigtoe Active Member

    "it is quite possible to have a foot in which the STJ axis which is medially deviated at one point in time during the contact period and laterally deviated at another"

    ah have not really been thinking about it that way, i think i have got into a bad habit of only locating the axis in the rearfoot and taking it for granted that it will follow the same pathway.

    "P.S. axes don't determine motion... "

    hi simon can you expand on that, am i right in thinking axes determine foot position???

    cheers scott
     
  7. Scott, I think you may be missing the point, it's not about axial location at the rearfoot versus at the forefoot, its about this axis changing position throughout the gait cycle, i.e. in time during dynamic function.

    Forces determine both the motion and the axial position, the axis isn't a rod through the foot waiting for a force to be applied to it. So if the joint is not moving, there isn't an axis, so what's the axial position in static stance? Answer: there isn't one- right? So can we perform a static assessment of axial position- no. This is important to understand.

    Also, consider this: the bigger the angle an axis makes to a plane, the more movement that is occurring in that plane. So consider two feet with STJ axial positions at a given point during dynamic function: both have the same "laterally deviated axis", but the pitch of the two axes differs, i.e. one makes a small angle to the transverse plane while the other makes a large angle- what differences might we see in the movement pattern and thus the quasi-static position of the two feet?
     
  8. bigtoe

    bigtoe Active Member

    "the axis isn't a rod through the foot waiting for a force to be applied to it"

    that whats confusing me as i had it in my head it was like a rod!!! back to the drawing board!!

    "consider two feet with STJ axial positions at a given point during dynamic function: both have the same "laterally deviated axis", but the pitch of the two axes differs, i.e. one makes a small angle to the transverse plane while the other makes a large angle- what differences might we see in the movement pattern and thus the quasi-static position of the two feet? "

    when you say angle in the transverse plane, should i be asking what direction??? if medial would you start to see pronation moments and if the angle increases then increased pronation???

    a confused but grateful

    scott
     
  9. I said angle "to", not "in".
     
  10. bigtoe

    bigtoe Active Member

    sorry i am abit out of my depth!!!
     
  11. Don't be sorry. If you tell me what don't you understand, I'll try to explain it in another way for you.
     
  12. bigtoe

    bigtoe Active Member

    "consider two feet with STJ axial positions at a given point during dynamic function: both have the same "laterally deviated axis", but the pitch of the two axes differs, i.e. one makes a small angle to the transverse plane while the other makes a large angle- what differences might we see in the movement pattern and thus the quasi-static position of the two feet? "

    the pitch you talk about, is it the angle from the ground upwards? if the pitch is higher on one foot will that mean the forces with be higher on that side, meaning that the movement pattern will be faster on this side? so due to the lateral axis you would see more supinatio faster on that side????

    cheers

    scott

    ps this might be a stupid question but how do we work out pitch???
     
  13. Scott:

    You have some very good questions here.

    As Eric and Simon have mentioned, saying the patient has a "laterally deviated subtalar joint (STJ) axis" can mean different things to different clinicians. First of all, the STJ axis location noted in the non-weightbearing examination (Kirby KA: Methods for determination of positional variations in the subtalar joint axis. JAPMA, 77: 228-234, 1987) may not, in fact, be the same STJ axis location noted during the weightbearing examination. When weightbearing, the foot can pronate or supinate from the plantar parallel position which is done in the non-weightbearing examination in the palpation test I originally described 23 years ago.

    Secondly, the STJ axis location test is only reliable at indicating the prevailing external STJ moments coming from the actions of GRF on the plantar foot during relaxed bipedal stance and will not necessarily be accurate in determining STJ moments during dynamic gait since internal STJ moments from muscle activity can easily overcome the external STJ moments from GRF that tend to cause STJ pronation and/or supination.

    Your example of the foot with a laterally deviated STJ axis that pronates during gait is a fairly common clinical scenario where the peroneal muscles are "over-active" during late midstance and cause the foot to pronate, even though GRF is tending to cause the foot to supinate. On the opposite side of your example, it is also common to see feet with medially deviated STJ axes that walk quite normally with good late midstance and propulsive supination because their posterior tibial muscles are strong and can resist the STJ pronation moments from GRF quite well.

    Therefore, the STJ spatial location during non-weightbearing or weightbearing examination does not necessarily determine how the foot will function, but simply gives the clinician one more valuable bit of information that helps them to determine the likely internal forces and moments acting on the foot and lower extremity during gait so that they can make better treatment decisions for their patients in pain.
     
  14. bigtoe

    bigtoe Active Member

    Hi kevin

    "Secondly, the STJ axis location test is only reliable at indicating the prevailing external STJ moments coming from the actions of GRF on the plantar foot during relaxed bipedal stance and will not necessarily be accurate in determining STJ moments during dynamic gait since internal STJ moments from muscle activity can easily overcome the external STJ moments from GRF that tend to cause STJ pronation and/or supination. "

    ok i am understanding this more clearly now. this would explain why muscles get injuried.

    "with a laterally deviated STJ axis that pronates during gait is a fairly common clinical scenario where the peroneal muscles are "over-active" during late midstance and cause the foot to pronate, even though GRF is tending to cause the foot to supinate. On the opposite side of your example, it is also common to see feet with medially deviated STJ axes that walk quite normally with good late midstance and propulsive supination because their posterior tibial muscles are strong and can resist the STJ pronation moments from GRF quite well."

    can i ask yet another question, i can understand the pronation moment during gait, but why would i see a pronated appearance in static assessment in this type of patient. my thoughts up to now have been based on hypermobility issues and or knee position such as genu valgum causing internal rotation.

    i also seem to have more questions than answers

    cheers

    scott
     
  15. Atlas

    Atlas Well-Known Member


    Goodness gracious, if KISS is keeping it simple....then this is spitting.


    My advice.

    1. Forget, even for a moment about the theoretical black hole.
    2. Establish the MAIN PROBLEM. As a podiatrist (assumption), you would know a bit about ankle instability and maybe a bit less about medial knee pain (assumption 2).

    3. Focus on the main problem which, in your terms-of-reference, would be knee pain and/or ankle instability.


    If the medial knee pain has a compressive underpinning then Craig's research with Hinman might be your saviour. Facilitating/increasing/augmenting evertion or pronatory (I know KK likes pronation instead of pronatory) forces will assist with ankle instability and "open up" a compressive medial knee.




    For goodness sake, worry about the cake, not the icing. Many musculo-skeletal professionals before you and after you, have and will be helping, these complex presentations without one thought lent to STJ axis location (and/or most of the podiatric biomechanical theory). Having said that, I like what pod biomechanics can do for the STJ and foot; and I like what STJ axis theory shows the over-enthusiastic physio that thinks peroneal strengthening is the panacea for all ankle conditions.


    God I feel sorry for the podiatry student sometimes.


    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
     
  16. Scott, don't let me put words into your mouth, but consider this: You assess STJ axial position non-weightbearing using the palpation technique described by Kevin, you ascertain that in this situation the STJ axis is laterally deviated. The patient stands up and the subtalar joint pronates... why is this so strange? what happens to the axial position as the joint pronates?
     
  17. Scott remember that forces define the position of the axis as has been written and that axis position can move during gait.

    The axis position may mean more/less work to create motion by muscles etc, muscle contraction may change the position of the stj axis and create a new point of stj axis equilibrium.

    By thinking this way Simons question should be easier to answer.


    hope that helps
     
  18. David Smith

    David Smith Well-Known Member

    Scott

    This is what I see very often when looking at a subject with genu valgum, valugus f/foot and lateral stj axis. In walking they adduct the hip, which when the foot is planted will also pronate the STJ (see vid) as the plantar CoF moves laterally.
    This lady is similar to your description I think. Genu valgum, stj axis lateral, valgus f/foot and yet pronating thru stance phase.




    Dave
     
    Last edited by a moderator: Sep 22, 2016
  19. Scott:

    Two distinct possibilities exist:

    1. You are erring on the side of a lateral subtalar joint (STJ) axis determination in your non-weightbearing (NWB) examination so that a patient with a medial to normal STJ axis location is determined, by you, to be a lateral STJ axis.

    2. As Simon noted, the foot is pronating in stance, most likely due to a overly compliant medial column so that the patient's STJ appears to be more lateral during NWB exam, then stands on the ground, pronates at the STJ due to the medial column being overly compliant, which causes the STJ axis to then become more medially deviated.

    The possibility that #2 is occurring is a known problem with the NWB STJ axis palpation method that I originally started performing over 25 years ago (Kirby KA: Methods for determination of positional variations in the subtalar joint axis. JAPMA, 77: 228-234, 1987). In other words, the weightbearing (WB) and NWB STJ axis locations may be different due to the effects of GRF or due to unknown muscular activity occurring during WB.

    Therefore, one option to get around this problem is to first, before NWB palpation of the STJ axis is started, stand the patient in relaxed bipedal stance and note where each foot's STJ is within its STJ range of motion (i.e. maximally pronated, 3 degrees from maximally pronated, etc). Then put the patient back up on the table and, when performing the STJ palpation method, hold the STJ in the rotational position that you saw on the ground to determine the STJ axis position. This will effectively indicate the true weightbearing STJ axis location that occurs once all the forces and moments acting on the foot have equilibrated during relaxed bipedal stance.

    For your information, when I train the third year surgery residents from Kaiser in my office every week, I use a weightbearing assessment of the STJ axis rather than my originally described palpation method to determine STJ axis location since it is more functional and takes much less time, even though it is also probably a less accurate method of STJ axis location determination than the NWB palpation method.

    Hope this helps some.
     
  20. Ron:

    I rather appreciate Scott's questions since he is earnestly trying to understand some difficult concepts.....instead of just taking what his teachers may have taught him as gospel truth. Once he gets a grasp of these concepts, then the foggy haze of confusion will dissipate and the sun will start to peak through, little by little. I know, since I remember these exact same sensations occurring to me when I was a young podiatrist racking my brain trying to understand conflicting observations versus what I was taught by the Root theorists. The important thing to note here is that this sensation will not likely occur without him going through the process of asking the questions and searching for the answers. It is sometimes the journey or process of acquiring valuable information that is more important for the clinician than what actual information is acquired.:drinks
     
  21. Atlas

    Atlas Well-Known Member

    Might have to agree to disagree on this one Kevin.

    I am all for asking questions. I am all for anyone wanting to learn and progress. Those of us that think we know-it-all, probably don't ask enough. (Actually, I have just been conversing with Gary Wilkerson at the University of Tennesse about strapping. He is not a Pod, nor a Physical Therapist, probably not even a pHD, but he is enlightening me greatly with the under-estimated mechanical effects of taping.)

    Back to the discussion.

    If I appear to be having a go at Scott, I unreservedly apologise and emphasise that this was never my intention.

    Scott's question represents the problems that not only students face, but the profession confronts as well IMO. Its no good searching for complex icing, when you can't make a basic cake. The way we are going is that we will be good at the complex, but average with the basics: a dangerous formula me thinks (Sorry Craig).


    Modern podiatric theory is a huge asset, and that is self explanatory. But it is also a huge liability (which is never emphasised on these boards unfortunately), particularly when a lot of us need to get the basics right first. Modern podiatric biomechanics is also a huge liability when Pods look at the ankle IMO; but that is for another time (2 weeks away) and place (Melbourne).



    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
     
  22. bigtoe

    bigtoe Active Member

    cheers for all the advice, I look forward to next week, to try out Kevins weightbearing assessment. David, the video is good example of want I am seeing. I have to get my head around the fact the axis can change during weightbearing something I was not aware of. Simon at this momet in time I am still not sure why non weightbearing the axis is lateral but on weightbearing the foot pronates, but hope to get back to you on that one soon.

    Atlas, when i first started bio clinics a few years back I would always put the foot into STJ neutral, quickly found out that not everyone reported with improvement, which has lead to me over the past wee while trying to look for more ingredients to make the cake as I was feeling the taste could be better, hopefully one day I will get closer.

    regards

    scott
     
  23. Scott, regardless of where an axis is, the foot will pronate about that axis if there is a net pronation moment. As my colleagues have said, this will be a result of a combination of internal and external moments. With this pronation will be a concomitant medial shift in the STJ axis.

    Think about gait, the foot should strike the ground with the subtalar joint supinated, thus the STJ axis should be in a lateral position, yet upon striking the ground we see rapid pronation because the net moment about the STJ is that of pronation. Rarely do we see supination during early stance because despite the fact that the STJ is supinated and viz. the axis is laterally deviated, the pronation moment is still greater than the supination moment. Look at some of the strike positions in the video linked to this post http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=139601&postcount=15 some of them are very supinated and as such the STJ axes of these individuals should be within the realms of what you would classify in your non-weightbearing assessment as "laterally deviated", how many of them don't pronate from this strike position?
     
  24. Scott, attached is an x-ray image of a foot in 3 rotational positions. Note how the axis (the white line) is medially deviated in one position of rotational equilibrium, yet lateral deviated in another. Can you guess the positions the foot was placed in to take these radiographs?
     

    Attached Files:

  25. bigtoe

    bigtoe Active Member

    Simon cheers for sticking with me on this

    ah!!!! they all have a pronation moments on heel strike!!of course they do, doh!, light bulb moment!

    xray 1= pronated position
    xray 2= neutral position
    xray 3=lateral position

    they are all the same foot proving that the axis can change!!! foot position and force will/can change axis
     
  26. bigtoe

    bigtoe Active Member

    Simon thanks for sticking with me on this i think i am getting somewhere.
     
    Last edited: Mar 6, 2010
  27. Griff

    Griff Moderator

    Bigtoe,

    You may fancy investing in Kevin's Foot & Lower Extremity Biomechanics Books, and here is a taste of why:

    Volume II, Chapter 3
    Subtalar joint axis mechanics and rotational equilibrium theory (p.19)
    Motion of the subtalar joint axis during weightbearing activities (p.21)
    Effect of subtalar joint axis location on subtalar joint moments (p.23)
    The balancing of moments across the subtalar joint axis (p.25)

    Volume III, Chapter 6

    Biomechanics of subtalar joint axis location (p.61)
    Significance of subtalar joint axis location to supination resistance (p.63)
    Plantar subtalar joint axis location: Its mechanical significance (p.65)
     
  28. Atlas

    Atlas Well-Known Member

    The xrays are a brilliant depiction of the dynamacy of the STJ location in different STJ positions. But how does this impact on treatment options?

    I recollect in the tertiary days, that a medially located STJ axis needed a lot of force (postero-medial) to combat (large) pronation (torque) and the mechanically advantaged peroneal musculature.

    Physics nomenclature is not my forte, so pardon me in advance. How does the new dynamic understanding translating to treatment options. How does this help Scott's patient? Is the next step an orthoses that has a changing role/impact through the gait cycle?


    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
     
  29. As I said in my first post to Scott in this thread: "Try posting to reduce the stress on the target tissue. Remember to think in 4-dimensions: it is quite possible to have a foot in which the STJ axis which is medially deviated at one point in time during the contact period and laterally deviated at another. Indeed, you may see significant shift in axial position from barefoot standing to shod walking. The axial excursion during dynamic function is key. Identify which tissue is under stress and when; then work out the biomechanical function of that tissue at that time. If you understand how foot orthoses work, you can then tailor your prescription appropriately."

    It is my understanding that Scott was not referring to one patient here. See above.


    Potentially. It's about using the orthosis to reduce the stress on the target tissue at the right time during gait.
     

  30. I'm glad you feel you are making positive progress, Scott. BTW, the three foot positions: x-ray 1 = maximal pronation, 2 = relaxed standing and 3 = maximal supination.
     
  31. Ron:

    I don't believe that Scott was asking solely how we should treat his patient or describe all the treatment options available to help this patient. Rather he was asking a question of why he noted his patient with what seemed to be a lateral subtalar joint (STJ) axis was pronating in gait.

    Even an automobile mechanic is expected to know in detail how the automoble he/she is repairing works and functions. In fact, I would expect the best automobile mechanics have a much greater understanding of function of automobile components when compared to a mediocre automobile mechanic. If this is the case, then wouldn't you also expect the podiatrist who is working on the part of the human body that is regularly subjected to the greatest magnitudes of external loading forces during daily activities to understand, in great detail, about the mechanical function of the foot? Wasn't Scott asking a question about foot biomechanics that should allow him to acquire a much better understanding of how his patient's feet work so that he can become a better "foot mechanic"?
     
  32. P.S. all foot orthoses have a changing role / impact through the gait cycle. Is this concept new to you and others, and worthy of a new thread?
     
  33. Don´t that they have to as every ground-shoe-foot-orthotic impact will be slightly different and therefore the role the that the orthotic has will be different every time ? Thats they way Ive been thinking.
     
  34. Think about how the net reaction force vector progresses during the contact phase, and how the shape of the foot-orthosis interface influences this.
     
  35. I´ll think on this, out the door for the drive home got to pack the computer up. Cars running. Anyone else feel free to jump in.
     
  36. Ok back.

    The orthotoic reaction force ( ORF)can only be equal and opposite to the force the foot applies to the orthotic. So the point of impact will be the place that the net force vector is at it highest it will then decrease. The only time that the vector can increase is if the foot applies more pressure on the device. This can be achieved by reducing the area of contact with the orthotic at times such as when the heel lifts and at toe-off.

    The shape of the foot-orthosis interface can not increase the amount of force vector but can change the angle of that force vector.

    ie the medial skive will cause a change in the angle of the ORF compaired to a flat heel.

    A more contured ( ie the shape of the foot) or a negative conture ( ie skive device ) will also return the force faster and this will mean that the orthotic will cause a earlier change in foot kinemetics during the gait cycle.

    note: I made up negative conture for heel skive not sure if it´s a good discription for a device which has had some of the positive foot mold removed in manufactor such as a heel skive or cuboid notch.
     
  37. bigtoe

    bigtoe Active Member

    Hi Ian

    "You may fancy investing in Kevin's Foot & Lower Extremity Biomechanics Books"

    yip i think i will be making an investment

    scott
     
  38. Atlas

    Atlas Well-Known Member

    With all this advanced knowledge about dynamic axes of rotation, I thought the next step in orthotic therapy would be to better target therapeutic orthotic reaction forces. I assume old school viewpoint was single static axis of rotation and hence the old-school therapy of ORF here would suffice.
    I assume newer school viewpoint in IAOR and more dynamacy. Accordingly, what can we do to orthotics to provide the most targeted therapeutic ORS pending the specific moving axis of rotation.


    And another point on futuristic science fiction orthotics:

    Surely, the rearfoot post (for instance) of an orthotic has a greater impact at heel strike than it does during heel lift. Likewise, a forefoot valgus wedge for instance comes into play at FF loading to toe-off I would assume.

    If I crystal ball it now, some clever dick in 100 years may be able to work out how the rear aspect of an orthotic can still maintain its strong influence after heel lift; and how the anterior aspect can have a beneficial impact outside FF-load - to - toe-off. Debate will remain regarding what would be the clinical benefit, but that may not be settled until we can actually achieve it.

    That is what I mean about futuristic orthotics having a more changing/dynamic function through different aspects of gait, in accordance with pathology (clinically) and the those dynamic axis of joint rotation (theoretically).




    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
     
  39. Andrea Castello

    Andrea Castello Active Member

    Hi All

    I have been following this thread with interest and a couple of questions popped up.

    1. Looking at the video that Dave provided, whilst there seems to be some pronation evident, I would not of thought it as any more than is required in normal gait (to act primarily as a shock absorption measure). Definitely not enough for me to worry about preventing the degree of it with an orthosis.

    My thought process is that due to the lack of propulsion in this instance there is no supination occuring through late midstance and toe off. This results in less resupination of the foot in general during the swing phase which in turn causes a more everted heel strike (which is exacerbated by the genu valgum). Thoughts?

    2. Could the genu valgum be caused due to muscular weakness in some areas and tightness in others, such as overly tight ilio-tibial band and weak gluteus medius?

    3. In light of some recent evidence (Nester etc), indicating significantly more movement in the talo-navicular and calcaneo-cuboid joints than the STJ and possible impact this has in gait in general, have we been focusing too much on the rearfoot at the expense of the forefoot in discussing what we are seeing in this type of case?

    I am by no means a biomechanical expert, rather I am interested in peoples thoughts and ideas on these and any other questions.

    Warm Regards

    Andrea
     
  40. David Smith

    David Smith Well-Known Member

    Cheers Dave Dave
     
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