3.

Pathomechanics

Justin Wernick, DP M

Rules of Compensation
Uncompensated
No range of motion available at the primary compensation site to neutralize the abnormal influence.

Partially Compensated
Limited range of motion available at the primary compensation site to partially neutralize the abnormal influence.

Fully Compensated
Adequate range of motion available at the primary compensation site to fully neutralize the abnormal influence.

Calcaneal Varus
Subtalar Varus
Definition of calcaneal varus: An inversion deformity of the posterior portion of the body of the calcaneus due to an incomplete derotation from its infantile position.

Figure 1.

Orthopedics | Pathomechanics

169

Examination
It is measured in respect to a bisection of the posterior aspect of the calcaneus and the lower one-third ofthe leg. Subtalar joint compensation requires the calcaneus to only go to the vertical.

Figure 2.

Mechanism of Injury
Pronation continues into midstance Calcaneus everts to the vertical Extrinsic frontal plane influences increase the demand to pronate Increased acceleration of subtalar joint pronation

170 The 2005 Podiatry Study Guide

Method of Compensation

Figure 3.

Figure 4.

Orthopedics | Pathomechanics

171

Fully Compensated Subtalar Varus

Calcaneus undergoes a larger excursion to evert to the vertical Leg continues to internally rotate Events continue into early midstance

Figure 5.

172 The 2005 Podiatry Study Guide

Haglunds Deformity
The posterior-lateral border of the calcaneus is usually very prominent. In a calcaneal varus foot type, the exaggerated inverted attitude of the calcaneus will be irritated by the counter of the shoe during the resupination phase of walking.

Figure 6.

Figure 7.

Orthopedics | Pathomechanics

173

Tailors Bunion
Since the rearfoot functions in a varus attitude, the forefoot will have the same attitude once footflat has occurred This will increase the ground reaction force load on the 5th ray causing it to pronate

Figure 8.

Figure 9.

174 The 2005 Podiatry Study Guide

Clinical Symptoms
Haglunds deformity Hammer toes, 4th & 5th Knee problems Medial strain Patello-femoral Bunions and tailors bunions Tyloma, 2nd and/or 3 and 4 metatarsals Postural symptoms, fatigue

Normal Radiograph-Lateral View

Figure 10. Lateral View

Continuous cyma line Visible sinus tarsi Body of talus parallel with weight-bearing plane Calcaneal inclination of both feet should be uniform Calcaneal inclination is index of foot framework Cuboid articular facet is evenly aligned with calcaneal articular facet

Orthopedics | Pathomechanics

175

Figure 11. Dorso Plantar View

Continuous cyma line Talar head closely aligned with anterior process of the calcaneus Long axis of the rearfoot is from the center of the calcaneus to the medial calcaneo-cuboid joint Talar head deviates 15 from the long axis 75% of talar head articulates with the navicular Lateral border of calcaneus parallels the long axis of the foot

Radiological Findings: Dorso-Plantar View

Thickening, 2nd metatarsal shaft Displaced sesmoids Cuneoform split Intact cyma line Pronated 5th ray

Figure 12 Dorso-Plantar View

176 The 2005 Podiatry Study Guide

Radiological Findings: Lateral View

Mild 1st ray elevatus Mild change in calcaneal inclination angle Intact cyma line

Figure 13. Lateral View

Concept of Function of the Orthoses

Decelerate and limit subtalar joint pronation by controlling calcaneal eversion. Expedite subtalar joint supination Control compensations at the midtarsal joint

Figure 14.

Orthopedics | Pathomechanics

177

Partially Compensated Subtalar Varus

With a limited range of motion at the subtalar joint The ability of the medial forefoot to reach the support surface is enhanced by 1st ray plantarflexion

Figure 15.

Clinical Symptoms
High arch appearance May develop lesion, plantar to the 1st metatarsal Lateral heel, knee and postural symptoms

Figure 16.

178 The 2005 Podiatry Study Guide

Block Test
We determine if we have a partially compensated subtalar varus or a rigid plantarflexed 1st ray by using the Block Test.

Figure 17. Block Test

Uncompensated Subtalar Varus

Since there is no range of motion available at the subtalar joint, the calcaneus will remain inverted as well as the forefoot, resulting in lateral foot and leg symtomology.

Symptomology
Lateral heel callus Lateral callus 5th metatarsal base and head

Figure 18.

Orthopedics | Pathomechanics

179

Forefoot Varus
Definition: A fixed osseous structural deformity where the forefoot is inverted to the rearfoot.

Figure 19.

Examination
It is measured with respect to a bisection of the posterior aspect of the calcaneus and the plane of the lesser metatarsals (2 - 4) when the subtalar joint is neutral and the midtarsal joint is maximally pronated.

Figure 20.

180 The 2005 Podiatry Study Guide

Subtalar Joint Compensation Requires the Calcaneus to go Beyond the Vertical.

Figure 21.

Subtalar Joint Compensation Requires the Calcaneus to go Beyond the Vertical.

Figure 22.

Orthopedics | Pathomechanics

181

In Order for the Forefoot to Reach the Support Surface, the calcaneus will Pronate Beyond the Vertical into Valgus.

Figure 23.

182 The 2005 Podiatry Study Guide

Figure 24.

Clinical Symptoms
Severe H.A.V. deformity Helomatyloma Heel pain Plantar fasciitis Posterior tibial dysfunction Back and postural complications Medial knee pain

Orthopedics | Pathomechanics

183

Morphology of the Arch with a Forefoot Varus Deformity

Since there is a marked inverted attitude to the forefoot, there is very little typography to the plantar of the foot.

Figure 25.

184 The 2005 Podiatry Study Guide

Radiological Findings: Dorso-Plantar View

Broken cyma line Increased talo-calcaneal angle Thickening, 2nd metatarsal shaft Talar head escape Cuneiform split

Figure 26. Dorso-Plantar View

Orthopedics | Pathomechanics

185

Radiological Findings: Lateral View

1st ray elevatus Lowering of the calcaneal inclination angle Broken cyma line Ptosis of the midfoot

Figure 27. Lateral View

186 The 2005 Podiatry Study Guide

Mechanism for Developing a Forefoot Supinatus

Since the plane of the forefoot cannot pronate as far as the subtalar joint at heel off, an inverted attitude of the forefoot to the rearfoot results.

Figure 28.

Figure 29.

Orthopedics | Pathomechanics

187

Concept of Function of the Orthoses

Decelerate and limit subtalar joint pronation by supporting the forefoot deformity Expedite subtalar joint supination Control compensations at the midtarsal joint

Figure 30.

Equinus
Definition: Any restriction of motion at the ankle joint that prevents the body from passing over the foot.

Figure 31.

188 The 2005 Podiatry Study Guide

Examination
Measured with the subtalar joint in neutral position and the knee fully extended.

Figure 32.

Etiology
Congenital Bony block of the ankle Short and/or tight triceps Spastic contractures of the triceps Acquired Constant and complete subtalar joint and oblique mt.jt. pronation Structural short leg Anterior tibial weakness

Compensation
What is the main factor that will determine how an individual will compensate for an equinus condition? Range of motion at the primary compensation site What is the primary compensation site for sagittal plane influences? Oblique axis of the midtarsal joint

Orthopedics | Pathomechanics

189

Uncompensated Equinus
With no range of motion available at the ankle and midtarsal joint, the heel will not make contact with the support surface.

Figure 33.

Partially Compensated Equinus

In each case, the compensations expedite the body passing from behind the support limb to in front of the support limb.

Figure 34.

190 The 2005 Podiatry Study Guide

With a limited range of motion at the ankle and midtarsal joint, the compensation can occur as: Knee flexion or extension Premature heel lift Out - toe gait Short stride Toe walking in children

Figure 35.

Figure 36.

Orthopedics | Pathomechanics

191

Fully Compensated Equinus

With an adequate range of motion at the midtarsal joint the compensation can occur as: Lowering of the calcaneal inclination angle Collapse of the arch With an adequate range of motion at the midtarsal joint the compensation can occur as: Lowering of the calcaneal inclination angle Collapse of the arch

Figure 37.

Figure 38.

192 The 2005 Podiatry Study Guide

Clinical Symptoms
Severe HAV deformity Corns and calluses Hammer toes Heel and arch pain Fatigue and postural symptoms Back pain

Figure 39.

Radiological Findings: Dorso-Plantar View

Broken cyma line Medial escape of the talus Abductus of the forefoot Less then 75% of the talar head articulates with the NAVICULAR

Figure 40. Dorso-plantar View

Orthopedics | Pathomechanics

193

Radiological Findings: Lateral View

Broken cyma line Decreased calcaneal inclination angle Increased talar declination angle Saddle shape to the tarsal region Cuboid lowers and everts

Figure 41. Lateral View

Figure 42. Lateral View

194 The 2005 Podiatry Study Guide

Concept of Orthotic Device Function

Fully Compensated
Decelerate calcaneal eversion Control plantarflexion of the distal portion of the calcaneus Control abduction of the forefoot Control medial shift of the tibia

Figure 43. Mild to Moderate Compensation

Use an accommodative device Raise the heel to decrease the demand on the midtarsal joint Use a proper lasted shoe to assist in support Use of a SMO

Figure 44. Severe Compensation

Use an accommodative device Raise the heel to decrease the demand on the midtarsal joint Use a proper lasted shoe to assist in support Use of a SMO Bring the support surface up to the heel to extend the weight-bearing period Balance abnormalities of the forefoot

Orthopedics | Pathomechanics

195

Forefoot Valgus
Definition: An osseous deformity of the forefoot in which the plane of all the lesser metatarsal heads is everted relative to a bisection of the posterior aspect of the calcaneus

Examination
Measured with the subtalar joint in neutral position and the midtarsal joint maximally pronated.

Planes of Deviation

Figure 45.

Rigid Platarflexed 1st Ray

Sometimes referred to as a rigid forefoot valgus. A congenital or acquired position of the 1st ray in which the 1st metatarsal head is fixed below the plane of the lesser metatarsal heads.

Figure 46. Rigid Plantarflexed 1st Ray

196 The 2005 Podiatry Study Guide

Flexible Plantaflexed 1st Ray

A condition where the 1st metatarsal head has migrated below the level of the lesser metatarsal head plane but can be easily moved back to or above that level by some force applied to its plantar aspect.

Figure 47. Flexible Plantarflexed 1st Ray

Examination for Position of the 1st Ray

Figure 48.

Orthopedics | Pathomechanics

197

Concept of Function: Rigid Plantarflexed Ist Ray

1st ray is plantar to the lateral forefoot plane 1st ray is plantar to the weight-bearing heel Generalized limitation of motion in the foot

Figure 49.

With limited range of motion in the longitudinal midtarsal joint, frontal plane compensation will take place via supination of the subtalar joint. With the forefoot plantar to the heel, compensation will occur as a lack of dorsiflexion at the ankle.

Figure 50.

198 The 2005 Podiatry Study Guide

With limited range of motion in the longitudinal midtarsal joint, frontal plane compensation will take place via supination of the subtalar joint. With the forefoot plantar to the heel, compensation will occur as dorsiflexion at the ankle.

Figure 51.

Clinical Symptoms Rigid Plantarflexed Ist Ray

Hammer toes Heel pain Lateral ankle sprains Lateral knee and hip pain Impact shock to the back Plantar lesions, 1st and 5th met. heads Sesmoiditis

Orthopedics | Pathomechanics

199

Concept of Function Flexible Plantarflexed Ist Ray

1st ray is plantar to the lateral forefoot plane 1st ray is plantar to the weight-bearing heel No limitation of motion in the foot

Figure 52.

With no limitation of motion in the longitudinal midtarsal joint, frontal plane compensation will take place via supination of the midtarsal joint and longitudinal axis. With the forefoot plantar to the heel, compensation will occur as dorsiflexion of the oblique midtarsal joint and the 1st ray.

Figure 53.

200 The 2005 Podiatry Study Guide

Clinical Symptoms Flexible Plantarflexed Ist Ray

Hammer toes Heel pain Arch pain Medial knee and hip pain Postural symptoms Plantar lesions, 2,3,4th metatarsal heads HAV deformity

Figure 54.

Figure 55.

Orthopedics | Pathomechanics

201

Radiological Findings: Lateral View

Broken cyma line, anterior Increased calcaneal inclination angle Decreased talar declination angle Humped shape to tarsal region

Figure 56. Lateral View

Radiological Findings: Dorso-Plantar View

Broken cyma line, anterior Lateral deviation of the talus Adductus of the forefoot Bi-partite sesmoids

Figure 57. Dorso-Plantar View

202 The 2005 Podiatry Study Guide

Concept of Function Of The Orthosis: Flexible Plantarflexed Ist Ray

Control calcaneal eversion Allow 1st ray stabilization Support midtarsal joint Align plane of 1st ray with the plane of the lesser metatarsals Control calcaneal inversion Raise heel to reduce need to dorsiflex ankle Align plane of 1st ray with the plane of the lesser metatarsals with bar or valgus post

Figure 58.

Orthopedics | Pathomechanics

203

204 The 2005 Podiatry Study Guide