Pes Cavus and Pes Planus

Analyses and Treatment

ABBY HERZOG FRANCO The arch of the foot serves as an adaptable, supportive base for the entire body. This article discusses how the arch of the foot affects the normal biomechanics of the lower limb. An anatomical overview of the three components of the arch of the foot is presented, identifying the medial longitudinal arch as the arch mainly responsible for related structural problems throughout the lower limb. Deviations in the normal structure of the medial longitudinal arch produce unbalanced, functionally unstable conditions of the foot such as pes cavus or pes planus. Specific evaluation criteria for both pes cavus and pes planus are discussed, in addition to the adverse effects these two disorders have on weight bearing, force dissipation, and normal gait. Compensatory pronation associated with pes planus is one of the most common lower extremity disorders seen currently by physical therapists working in sports medicine, and its causes and related lower limb disorders are discussed. Most of these structural deformities can be corrected through the use of various orthotic devices. Specific guidelines are presented for using both soft and permanent orthoses, which offer the foot increased shock absorption and proper structural alignment. Key Words: Foot, Orthotic devices, Physical therapy.

A functional relationship exists between the structure of the arch of the foot and the biomechanics of the lower limb. The arch of the foot provides an elastic, springy connection between the forefoot and the hindfoot. This relationship ensures that most of the forces incurred during weight bearing can be dissipated before reaching the long bones of the leg and thigh. The arch of the foot demonstrates two extremes of anatomical structural positionthe high arch characteristic of pes cavus and the flat arch characteristic of pes planus. Although three distinct arches function to support the foot, the medial longitudinal arch (MLA) has been found to be the arch of clinical significance in both of these disorders. Problems and malalignments originating specifically with the MLA ultimately affect the functioning of the muscles and joints of the ankle, knee, hip, and low back, all of which depend on the base of support provided by the MLA. A strong need exists for physical therapists to understand applied anatomy and biomechanics of the arch of the foot
Ms. Franco is a student in the physical therapy program, Florida International University, Tamiami Trail, Miami, FL 33199. She was Head Athletic Trainer, Barnard College of Columbia University, 606 W 120 St, New York, NY 10027, when this study was conducted. Address correspondence to 8181 Boca Rio Dr, Boca Raton, FL 33433 (USA). This article was submitted March 27, 1986; was with the author for revision three weeks; and was accepted July 23, 1986. Potential Conflict of Interest; 4.

as it relates to common lower limb disorders. Muscular imbalances, structural malalignments of joints, compensatory pronation of the foot, and gait abnormalities often are caused by pes cavus or pes planus. After a comprehensive evaluation, the physical therapist can use various orthotic devices to balance the foot and restore normal function of the lower limb.
ANATOMICAL OVERVIEW

The intricate alignment of the bony structure of the foot, produced by the tarsal and metatarsal bones and their corresponding ligaments, results in the interdependent formation of one transverse and two longitudinal arches. These supporting arches are designed to absorb and distribute body weight and to improve locomotion by increasing speed and agility during gait. The plantar arches provide both stability and flexibility, meeting the different, complex requirements of the foot at different phases of the gait cycle.1-5 The arches must act as a rigid lever for proper mobility, but they also must be resilient and flexible for adaptation to different surfaces. The design of the arches can be understood by picturing the foot as a twisted osteoligamentous plate.2 The anterior edge of the plate (formed by the metatarsal heads), is horizontal and in full contact with the ground. The posterior edge of the plate (the posterior calca-

neus), is vertical. The resulting twist forms the longitudinal and transverse arches. During weight bearing, the plate will untwist, flattening the arches slightly. As the foot is unloaded of weight, the resilient arches return to their original shape. The actual mechanism of twisting and untwisting is accomplished through motion at the talocalcaneonavicular, transverse tarsal, and tarsometatarsal joints that link the bones of the plantar arches.2 The transverse arch of the forefoot is located immediately behind the metatarsal heads and can be visualized spanning across the tarsometatarsal joints, its integrity being maintained by the wedge-shaped cuneiforms. The middle cuneiform serves as the keystone of the transverse arch.6 At the level of the metatarsal heads, the curvature of the arch is reduced greatly because the metatarsal heads are in alignment, parallel to the weight-bearing surface. Also assisting in holding the base of the arch together are the tendons of the peroneus longus muscle, the oblique head of the adductor hallucis muscle, and the flexor hallucis brevis muscle.7 The longitudinal arches, both medial and lateral, are supported by the plantar ligament arising from the calcaneus and extending forward to attach to the metatarsals near the heads.8 The longitudinal arch also is supported by the plantar aponeurosis, which is the dense fascia that spans from the calcaneus to the
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alone maintain the arched form of the foot.11 The MLA, which is the arch of clinical significance in both pes cavus and pes planus, will be the arch referred to in the remainder of this article.
NORMAL WEIGHT BEARING AND FORCE DISSIPATION

Fig. 1. Supporting structures of the medial longitudinal arch: 1) The tibialis anterior, 2) the tibialis posterior, 3) the spring ligament, 4) the plantar aponeurosis.

proximal phalanx of each toe.4,9 The lateral longitudinal arch is formed by the bony structural relationship between the calcaneus, cuboid, and metatarsals, with the cuboid serving as the keystone of the arch.10 Both the long and short plantar ligaments restrict motion at the calcaneocuboid aspect of the transverse tarsal joint by maintaining the normal twist between the forefoot and hindfoot. The integrity of the MLA is preserved by the bony structure of the foot, strong ligaments, and active muscles (Fig. 1). The MLA is composed of five bones, with the navicular serving as the keystone of the arch.6 The spring ligament, or the plantar calcaneonavicular ligament, is the main support of the MLA.1 As the spring ligament crosses the transverse tarsal joint (the calcaneocuboid and talonavicular joints), it restricts joint motion that contributes to the flattening of the arch. During weight bearing, the spring ligament offers some elasticity and springiness to the arch.2 Normally, the dorsum of the foot is domed because of the MLA. The arch is more prominent in the nonweightbearing position than in the weightbearing position. The MLA is reinforced further by the tibialis anterior and tibialis posterior muscles, whose tendons pull the medial border of the foot upward.6 The long flexor muscles, whose
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In normal weight bearing, forces are transmitted through the talus to the medial aspect of the foot, specifically to the talonavicular part of the transverse tarsal joint, causing pronation of the forefoot. The weight of the body drives the head of the talus downward between the calcaneus and the navicular, and this force is resisted by the spring ligament.7 This downward motion is accompanied by eversion of the calcaneus at the subtalar joint and slight depression of the navicular.4 In the normal foot, the lateral portion of the MLA rests on the ground. This contact, in addition to the absorption of forces at allfivemetatarsal heads, offers additional support to the foot (Fig. 2). In the properly aligned foot, the calcaneus is in a vertical position, perpendicular to the horizontal metatarsal heads. Because the metatarsals must remainflaton thefloorfor weight bearing, their positional relationship with the calcaneus and thus the shape of the MLA are controlled by the plantar aponeurosis. Hicks found that the plantar aponeurosis absorbed about 60% of the stress of weight bearing.12,13 As the toes are extended during the push-off phase of gait, the increased tension in the plantar aponeurosis raises the MLA by facilitating supination (Fig. 3). This mecha-

Fig. 2. Normal foot. Weight bearing is distributed evenly on all five metatarsal heads.

tendons are attached to the foot behind the medial malleolus and under the MLA, also offer support and act like a sling.7 Evidence exists, however, that the muscles related to the arch are inactive during standing and that the ligaments

Fig. 3. Windlass effect. Tightening of the plantar aponeurosis on push-off increases the medial longitudinal arch. This increase stabilizes the foot during ambulation as weight is shifted onto the ball of the foot.

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nism is known as the windlass effect.13 The pronation that occurs immediately on weight bearing slightly flattens the MLA, which aids in the absorption of shock. PES CAVUS In the extremely high-arched foot characteristic of pes cavus, weight bearing is distributed unevenly along the metatarsal heads and along the lateral border of the foot (Fig. 4). This type of disorder causes the foot to be prone to metatarsal head and calcaneal contusions resulting from the excessive pressure of weight bearing. The foot also is prone to osteophyte formation at the junction of the metatarsal bases and the cuneiforms. This area is quite prominent under the skin and quite susceptible to damage.8 To identify pes cavus, the patient should sit at the edge of a tabletop with his foot dangling in a nonweight-bearing position. If the forefoot is lower than the heel and the arch is high but depresses on weight bearing, the patient's condition may be diagnosed as "flexible" pes cavus. If the arch remains high when the patient is in a full weight-bearing position, the condition is "rigid" pes cavus.14 The foot with flexible pes cavus usually displays a callus under the second metatarsal head. This condition is caused by the arch's inability to dissipate forces and lack of shock absorption. The foot with flexible pes cavus responds well to orthotic devices, which support the MLA, balance the foot, and provide shock absorption. The foot with rigid pes cavus poses additional problems. Besides callus formation under the first, second, and fifth metatarsal heads, these feet have tight, cordlike plantar fascia resulting from the stresses created by the high arch. The abnormal stresses produced by the structural problems of a rigid, high-arched foot also tighten the Achilles tendon and produce claw toes.9 Because of poor shock absorption and a very small weight-bearing area, feet with eitherflexibleor rigid pes cavus are prone to heel pain and stress fractures, in addition to various shock-related pathological conditions that are transmitted up the leg to the knees and hips 8,10,14,15 Both types of pes cavus u s u _ ally are accompanied by excessive inversion at the subtalar joint and supination of the forefoot at the transverse tarsal joint (Fig. 5).4 Calluses develop under the metatarsal heads when abnormal weight bearing must be accommo690

dated. The forces of weight bearing commonly are shifted to the dropped head of the second metatarsal, causing plantar callus formation.16 Treatment for this condition should be directed at providing arch support, structural alignment, and shock absorption through the use of orthotic devices and should include stretching of tight musculature throughout the lower limb. The orthotic device for a high-arched foot usually is made of soft, flexible materials to increase foot shock absorption. These softer, flexible materials often compromise joint control, however, making treatment for this condition more difficult. The physical therapist can further help the patient with pes cavus by evaluating the lower limb for muscular imbalances. Tight ankle inverter and plantar flexor muscles and weak ankle everter muscles often accompany pes cavus. Stretching the tibialis posterior and the gastrocnemiussoleus complex and strengthening the peroneal muscles will help to balance the foot's supporting structures in an effort to restore the foot to its proper alignment. PES PLANUS In pes planus, the head of the talus is displaced medially and plantarward from the navicular. This displacement stretches the spring ligament and the tendon of the tibialis posterior muscle,

Fig. 5. Supinated foot with pes cavus. Note the inversion at the subtalar joint.

Fig. 4. Foot with pes cavus. Weight bearing is on the lateral border of the foot and first, second, and fifth metatarsal heads.

resulting in the loss of the MLA.16 Because of this medial displacement of the talar head, a callus may develop where the prominent talar head presses against the medial counter of the shoe. When viewed from the posterior aspect of the foot, the calcaneus will be everted. The person whose calcaneus is in valgus will have a relativelyflat-archedfoot because of the untwisting of the interconnecting ligaments of the forefoot and the hindfoot. If the MLA is absent in both seated and standing positions, the patient has "rigid" flatfoot. If the MLA is present while the patient is sitting or is standing up on the toes, but disappears during foot-flat stance, he has "supple" flatfoot, which is correctable with arch supports.16 The flattening of the MLA disrupts the normal process of weight bearing and causes functional changes in the foot. Many people with pes planus demonstrate a flat-footed gait with no toeoff,10 often associated with a large plantar weight-bearing surface (Fig. 6). Symptoms include a pronated foot, a shortening of the everter muscles of the foot (ie, the peroneal muscles), tenderness of the plantar fascia, and laxity of the supporting structures of the medial side of the foot (ie, the medial ligaments or deltoid group) and the tibialis posterior tendon.17 Over time, this functional PHYSICAL THERAPY

Fig. 6. Foot with pes planus. Note large weight-bearing surface with main force absorption on first and second metatarsal heads.

ray. Pronation is a component of a more complex motion, eversion. Eversion of the forefoot is a combination of movements in all three planes (ie, pronation, dorsiflexion, and abduction).1,4,5 In the initial phase of gait, the foot contacts the ground in supination. This inversion of the calcaneus at the subtalar joint locks the forefoot and provides the rigid lever to absorb the force of heelstrike. Immediately after heel-strike, the hindfoot pronates to unlock the transverse tarsal joint and create a loosepacked position in the forefoot. As the posterior aspect of the calcaneus rolls laterally, the sustentaculum tali of the talus rolls medially, producing the pronation.1119 The direct effect of this pronation is to create a shortening of the lower limb immediately after heelstrike, while providing a small degree of shock absorption.3 This change allows the foot greater flexibility of movement to adapt to changing ground surfaces. When the foot overpronates during this phase, the tibia also rotates medially, causing the knee to flex earlier than

deformity will develop into a chronic structural deformity, and abnormal stresses will be transferred to more proximal areas, affecting the knees, hips, and low back. Pes planus is not necessarily symptomatic. Many cases of fallen arches are painless because the foot adapts by changing the shape of bones and by the stretching of ligaments. The structural changes that accompany a flat-arched foot, however, affect the normal biomechanics of the lower extremity. Pronation, which is a normal component of gait, becomes exaggerated in the foot with pes planus. The lack of an arch maintains the foot in a flexible, unstable position, hindering normal gait and creating a wide variety of compensatory pronation disorders. An understanding of the components of pronation and its role during gait is necessary before the compensatory pronated foot can be discussed. PRONATION AND GAIT Pronation is an integral component of the stance phase of gait. Normal pronation is 4 to 8 degrees.15,18 Pronation for a foot with pes planus is between 10 and 12 degrees.15 Pronation of the forefoot, which causes flattening of the MLA, also flattens the transverse arch by splaying or spreading the metatarsals. The movements of pronation and supination are produced when the foot rotates around its long axis, the second
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PRACTICE normal. This flexion puts abnormal stresses on the quadriceps femoris muscles, which are contracting eccentrically to control knee flexion.4 In the late stance phase of gait, the foot again must function more as a rigid lever. This action requires an elevated arch and a locked forefoot. The foot inverter muscles, in addition to the secondary actions of the triceps surae and tibialis anterior muscles, cause the calcaneus to invert at the subtalar joint. This inversion produces supination at the transverse tarsal joint and lateral rotation of the tibia.11 The act of supination causes the osteoligamentous plate of the MLA to twist and tighten, which elevates the arch and locks the foot, providing the rigid lever needed for push-off. A flat-footed person requires more muscle action than a nonflat-footed person to support and propel the weight of his body.2 In pes planus, the hindfoot is in valgus (Fig. 7). This eversion at the subtalar joint creates an untwisted foot with little or no ligamentous support. If, at heel-strike, this foot makes impact in the valgus position, the foot is mobile already and is unprepared to act as a rigid lever to absorb these ground forces. The foot, therefore, must rely on accessory muscles for stabilization. This activity fatigues not only the extrinsic muscles but also the intrinsic muscles of the foot, which are functioning maximally to compensate for the lack of ligamentous support. COMPENSATORY PRONATION The most common pathomechanical problem associated with pes planus is compensatory pronation. Overpronation and pes planus are key factors in preventing the subtalar joint from locking during the complex biomechanical functioning of the lower extremity. This failure of the subtalar joint to lock creates a hypermobile foot, setting the stage for structural deformities and problems throughout the lower quarter. The physical therapist can use three static observations to detect abnormal pronation: 1) Helbing's sign, the medial bowing of the Achilles tendon secondary to calcaneal valgus; 2) Feiss's line, indicating the position of the navicular in relation to a line drawn between the first metatarsophalangeal joint and the medial malleolus; and 3) the amount and placement of callus formation, usually thicker under thefirstand second metatarsal heads and the medial, plantar surface of the calcaneus.15 691

Fig, 7. Pronated foot with pes planus. Note the eversion at the subtalar joint and the medial displacement of the talus and navicular.

A common cause of overpronation is a limitation of muscular flexibility anywhere along the lower limb. A tight triceps surae causes an early heel-off, which does not allow adequate time for resupination.15 Tight hamstring, hip flexor, iliotibial band, and hip medial rotator muscles all produce a toe-out gait. Toeing out prevents the foot from resupinating before toe-off, leaving a flexible, unstable foot. Compensatory pronation is associated often with other lower extremity disorders. In the patient with a leglength discrepancy, excessive pronation of the foot generally is a telltale sign of a longer limb.15 This pronation is accompanied usually by early knee flexion and longer stance time on the longer limb. In runners who train on paved roads, a functionally longer limb is created unconsciously by the "crowning" of the road. The sloped surface of the road will cause pain on the "downside" leg, the functionally longer limb. On a small track with sharp-banked curves, medial knee pain usually will occur on the "inside" leg. Forces are transmitted up the leg as the downside foot overpronates in an attempt to make a functionally longer limb shorter. Another common cause of overpronation is forefoot varus (Fig. 8). This disorder can be detected by sitting the patient on a treatment table with his foot hanging over the edge of the tabletop. With the subtalar joint in a neutral position, the forefoot will hang in an inverted position at rest. This congenital deformity originates as a supinated foot, but gravity pulls the medial aspect of the foot down when making contact with the ground during weight bearing. The foot thus becomes excessively pronated because of the overcompensation of bringing the foot to the ground. In addition to the common problems of tight peroneal muscles and stresses up the lower extremity, which can lead to such problems as shin splints, Hughes found that soldiers with a greater than normal forefoot varus are 8.3 times more likely to develop a stress fracture than soldiers with normal forefoot varus.20 A valgus deformity causes the first metatarsal to contact the ground before the fifth metatarsal, which forces all loads to the medial aspect of the foot. The first metatarsal head is twice the size and can absorb 2.6 times the force of the second metatarsal head.20 The head and shaft of the second metatarsal of the overpronating foot with pes planus, therefore, commonly develop 692

Fig. 8. A. Normal relationship between the hindfoot and forefoot. Note that the calcaneus and metatarsal heads are perpendicular. B. Forefoot varus. The forefoot rests in an inverted position relative to the subtalar joint, which is in a neutral position. (Adapted from Wallace.15)

callosities and stress fractures, respectively. Overpronation of the forefoot can lead to subsequent malalignments of the entire lower limb. In response to overpronation, the tibia will rotate medially. In these patients, the hip adductor muscles will be tight, and the external rotator muscles will be weak. The knee tends to assume a valgus position when the foot pronates. The distractive forces on the medial side of the knee lead to medial knee pain. The increased valgus also affects the proper tracking mechanism of the patella, predisposing the knee to chondromalacia and other patella tracking dysfunctions.1017 Unilateral pronation, if allowed to progress to more cephalic joints, will lead to a scoliosis. Bilateral pronation will increase the lordosis of the lumbar spine.21 Decreasing pronation appears to increase the stability of the extensor mechanism of the knee and decrease runners' knee symptoms.22 Treatment for the overpronated foot with pes planus should revolve around reducing the stresses that caused the problem. Long-distance runners with foot, knee, or hip pain secondary to pes planus should reduce their mileage, or perhaps even temporarily stop running, to allow the tissues to heal. A muscle strengthening program to strengthen the anterior and posterior tibialis and intrinsic foot muscles might increase the muscular support of the arch, forcing muscles to absorb most of the load. Other

treatments include arch taping or supports, ultrasound to heal damaged tissues, stretching of tight muscle groups, and orthotic devices. An understanding of the principles behind the use of orthotic devices will enable the physical therapist to correct both pes cavus- and pes planus-related problems by realigning the weight-bearing surfaces of the foot. ORTHOTIC DEVICES After a comprehensive lower extremity evaluation applying their background knowledge of the anatomy and kinesiology of normal foot function, physical therapists should be able to construct foot orthoses to balance the body's base of support. By following several simple principles and using readily available, inexpensive materials, normal foot function can be restored in minutes. An orthosis is a soft, semiflexible or rigid, device whose purpose is to balance the foot in the neutral position during the gait cycle. Soft, temporary supports can be made by adding felt and other soft materials to the insoles of the shoes. These materials, which will adapt to the contours of the foot, help correct problems such as abnormal pronation and supination, offer metatarsal and arch support, and provide better shock absorption. The main function of an orthotic device is to provide a combination of neuromuscular reeducation and a change in body mechanics in an atPHYSICAL THERAPY

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Fig. 9.

Structural tripod of the foot: the calcaneus and the first and fifth metatarsal heads.

tempt to readjust the foot into a more ideal weight-bearing position. Arch supports support the arch of the foot; however, they do not balance or offer mechanical control to the foot. When making orthotic devices for a patient, several principles should be kept in mind. Most important, undercorrection is the preferred treatment protocol. Maximal foot control is unnecessary, and a balancing effect of the foot is best. Visualize the foot as a structural tripod, with the heel and the first and fifth metatarsals as the bases of support (Fig. 9). The purpose of the orthotic device is to fill in the space between the balanced foot and the ground. Imagine bringing the ground up to the foot. When correcting an overpronating foot, remember that the foot has a natural tendency to pronate to some degree, usually 4 to 8 degrees.15,18 An orthotic device should not block all pronation. In addition, an entire lower quarter examination must be performed involving an assessment of muscle strength and flexibility and proper joint function. An orthotic device consists of two basic parts: 1) the base, the material you start with, and 2) the post, or the extra material that is added to the base to

"bring the ground up to the foot." In forefoot varus, the medial aspect of the foot is posted. Most compensatory pronation problems can be corrected by balancing in this manner.23 In the patient with anteromedial knee pain caused by excessive pronation, orthotic devices balance the heel at contact, support the arch at mid-stance, and allow eversion at the subtalar joint just before push-off.24 For pes cavus, a 0.25-in* felt heel lift and a lateral 0.12-in forefoot extension between the lateral half of the hindfoot and the fourth and fifth metatarsal heads have been found to be helpful.22 Soft, temporary supports wear down quickly, and readjustments must be made as needed. A wide variety of temporary orthotic devices can be made on the spot with minimal supplies and time.15,25,26 When making temporary orthotic devices for a patient, the physical therapist might want to use athletic tape either to tape the posting materials into the shoes or to bind the patient's feet into the desired position. When the correct temporary support is given and foot function has improved substantially, a
*1in = 2.54 cm.

permanent orthotic device should be custom made. Permanent orthotic devices are made from a positive model cast of the foot. The two methods most often used are the foam box impression and a plasterof-Paris slipper cast impression, both taken with the subtalar joint held in a neutral position. The neutral position of the foot is maintained when the long axis of the lower limb and the vertical axis of the calcaneus are parallel. Thermoplastic, or heat pliable, orthotic materials are molded onto the positive models to form the base. Postings and more durable materials then are added to complete the correction. In unidirectional sports, such as running, an orthosis can help the foot attain a neutral position at the middle of midstance. Rigid orthotic devices, made from a hard plastic material, are preferred by runners and by patients for use during walking and normal daily activities. In sports in which pivoting is involved or multidirectional forces are placed on the foot, the orthosis must provide arch control while allowing eversion at the subtalar joint to offer more forefoot flexibility.22 Semiflexible orthotics, made of leather and more pliable materials, are preferred by these athletes.
SUMMARY

The arches of the foot play an integral role in determining the proper mechanics of the entire lower limb. Both pes cavus and pes planus demonstrate typical patterns of structural deformity. Through an understanding of lower limb biomechanics, the physical therapist can evaluate and recognize structural imbalances and other disorders that originate with the arch of the foot. When detected, various related, symptomatic pathological conditions may be treated and relieved by balancing the foot through the use of orthotic devices.

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REFERENCES
1. DiStephano VJ: Anatomy and biomechanics of the ankle and foot. Athletic Training 16(Spring):43-47, 1981 2. Basmajian JV, MacConaill MA: Muscles and Movements: A Basis for Human Kinesiology. Baltimore, MD, Williams & Wilkins, 1969 3. McPoil TG, Knecht HG: Biomechanics of the foot in walking: A functional approach. Journal of Orthopaedic and Sports Physical Therapy 7:69-72, 1985 4. Norkin C, Levangie P: Joint Structure and Function: A Comprehensive Analysis. Philadelphia. PA, F A Davis Co, 1983, pp 331-365 5. Root ML, Orien WP, Weed JN: Clinical Biomechanics: Normal and Abnormal Function of the Foot. Los Angeles, CA, Clinical Biomechanics Corp, 1977, vol 2 6. Kapandji IA: The Physiology of the Joints: Lower Limb. Baltimore, MD, Williams & Wilkins, 1970, vol 2, pp 196-219 7. Joseph J: A Textbook of Regional Anatomy. Baltimore, MD, University Park Press, 1982 8. O'Donoghue DH: Treatment of Injuries to Athletes. Philadelphia, PA, W B Saunders Co, 1976, pp 747-790 9. Roy S: How I manage plantar fasciitis. The Physician and Sportsmedicine 11 (10): 127131,1983 10. Kessler RM, Hertling D: Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. Philadelphia, PA, Harper & Row, Publishers Inc, 1983, pp 448503 11. Donatelli R: Normal biomechanics of the foot and ankle. Journal of Orthopaedic and Sports Physical Therapy 7:91-95, 1985 12. Hicks JH: Mechanics of the foot: 1. The joints. J Anat 87:345-357, 1953 13. Hicks JH: Mechanics of the foot: 2. The plantar aponeurosis. J Anat 88:25-30, 1954 14. Subotnick S: The cavus foot. The Physician and Sportsmedicine 8(7):53-55, 1980 15. Wallace L: Lower Quarter Pain! Mechanical Evaluation and Treatment. In: Symposium on Lower Quarter Pain. Lake Worth, FL, November 23-24, 1985. 16. Hoppenfeld S: Physical Examination of the Spine and Extremities. New York, NY, Appleton-Century-Crofts, 1976, pp 197-235 17. Cooper D, Fair J: Managing the pronated foot. The Physician and Sportsmedicine 7(5): 131, 1979 18. Eggold J: Orthotics in the prevention of runners overuse injuries. The Physician and Sports medicine 9(3): 124-131, 1981 19. Perry J: Anatomy and biomechanics of the hindfoot. Clin Orthop 177:9-15, 1983 20. Hughes LY: Biomechanical analysis of the foot and ankle for predisposition to developing stress fractures. Journal of Orthopaedic and Sports Physical Therapy 7:96-101, 1985 21. Kisner C, Colby LA: Therapeutic Exercise: Foundations and Techniques. Philadelphia, PA, F A Davis Co, 1985, pp 377-396 22. Subotnick S: Foot orthoses: An update. The Physician and Sportsmedicine 11 (8): 103-109 1983 23. Rodgers MM, LeVeau BF: Effectiveness of foot orthotic devices used to modify pronation in runners. Journal of Orthopaedic and Sports Physical Therapy 4:86-90, 1982 24. Bates B: Foot orthotic devices to modify selected aspects of lower extremity mechanics. Am J Sports Med 7:338-342, 1979 25. Doxey GE: The semi-flexible foot orthotic: Fabrication and guidelines for use. Journal of Orthopaedic and Sports Physical Therapy 5:2629, 1983 26. McPoil TG: The cobra pad: An orthotic alternative for the physical therapist. Journal of Orthopaedic and Sports Physical Therapy 5:30-32,1983

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