A multi-segment kinematic model of the foot with a novel definition of forefoot motion for use in clinical gait analysis during walking

A multi-segment kinematic model of the foot was developed for use in a gait analysis laboratory. The foot was divided into hindfoot, talus, midfoot and medial and lateral forefoot segments. Six functional joints were defined: ankle and subtalar joints, frontal and transverse plane motions of the hindfoot relative to midfoot, supination/pronation twist of the forefoot relative to midfoot and medial longitudinal arch height-to-length ratio. Twelve asymptomatic subjects were tested during barefoot walking with a six-camera optical stereometric system and auto-reflective markers organized in triads. Repeatability of the joint motions was tested using coefficients of multiple correlation. Ankle and subtalar joint motions and twisting of the forefoot were most repeatable. Hindfoot motions were least repeatable both within-subjects and between-subjects. Hindfoot and forefoot pronation in the frontal plane was found to coincide with dropping of the medial longitudinal arch between early to mid-stance, followed by supination and rising of the arch in late stance and swing phase. This multi-segment foot model addresses an unfortunate shortcoming in current gait analysis practice-the inability to measure motion within the foot. Such measurements are crucial if gait analysis is to remain relevant in the orthopaedic and rehabilitative treatment of the foot and ankle.     

Microevolutionary changes in the skeleton of the foot of Japanese: Special reference to the medial longitudinal arch

This study concerns secular changes of the foot of Japanese, from the prehistoric Jomon period to early modern times. The size of the talus, calcaneus and first metatarsal changed in parallel with the estimated stature, during this period. In the case of the calcanues, length-height-index, length-tuberosity height-index, Böhler's tuber-joint angle and angle of cuboidal articular surface gradually increased with time. Thus, all may take part in elevation of the longitudinal arch. With time, the relative height of the subtalar, talonavicular, cuneonavicular and first tarsometatarsal joints in the reconstructed medial arch enlarged, in parallel with the increase in the inclination angles of both the calcaneus and the first metatarsal. In addition, valgus deviation of the distal phalanx of the great toe became conspicuous in comparatively recent times. These changes no doubt were accelerated by modification in life style.     

Effect of subtalar arthroereisis on the tibiotalar contact characteristics in a cadaveric flatfoot model

Previous studies reported the effect of flatfoot deformity on tibiotalar joint contact characteristics. The lateral shift of the load which occurred in flatfeet may be responsible for degenerative changes in the ankle joint. The purpose was to assess the pattern of joint contact stress of the tibiotalar joint in intact, flat, and corrected specimens with subtalar arthroereisis. Seven fresh-frozen cadaver specimens were studied in the intact and flat-footed condition after transection of ligaments which support the medial arch. Ankle joint contact stress and plantar pressure patterns were determined from a capacitive pressure sensor inserted in the tibiotalar joint and a pressure distribution platform when the specimens were axially loaded in simulated mid-stance. Contact pressure was also assessed after subtalar arthroereisis with a 12 mm Kalix implant for correction of the flatfoot deformity. A maximum contact pressure of 1414.2±319.2 kPa was recorded in the middle-medial region in intact specimens. Flatfoot caused a lateral shift in the pressure distribution (p<0.05). In the flat specimens, the maximum contact pressure of 1394.7 8±470.5 kPa was in the anterior-central region. After subtalar arthroereisis with the Kalix implant for correction of the flatfoot deformity a maximum contact pressure of 1323.3±497.5 kPa was observed in the middle-lateral region. In a cadaver model, subtalar arthroereisis with Kalix implant failed to restore a normal intraarticular ankle joint pressure pattern. Further interventions should be considered to restore a normal pressure pattern.     

In vivo determination of the anatomical axes of the ankle joint complex: An optimization approach

This study investigates the feasibility of a subject-specific three-dimensional model of the ankle joint complex for kinematic and dynamic analysis of movement. The ankle joint complex was modelled as a three-segment system, connected by two ideal highe joints: the talocrural and the subtalar joint. A mathematical formulation was developed to express the three-dimensional translation and rotation between the foot and shank segments as a function of the two joint angles, and 12 model parameters describing the locations of the joint axes. An optimization method was used to fit the model parameters to three-dimensional kinematic data of foot and shank markers, obtained during test movements throughout the entire physiological range of motion of the ankle joint. The movement of the talus segment, which cannot be measured non-invasively, is not necessary for the analysis.

This optimization method was used to determine the position and orientation of the joint axes in 14 normal subjects. After optimization, the discrepancy between the best fitting model and actual marker kinematics was between 1 and 3 mm for all subjects. The predicted inclination of the subtalar joint axis from the horizontal plane was 37.4±2.7°, and the medial deviation was 18.0±16.2°. The lateral side of the talucrural axis was directed slightly posteriorly (6.8±8.1°), and inclined downward by 7.0±5.4°. These results are similar to previously reported typical results from anatomical, in vitro, studies. Reproducibility was evaluated by repeated testing of one subject, which resulted in variations of about one-fifth of the standard deviation within the group, the inclination of the subtalar joint axis was significantly correlated to the arch height and a radiographic ‘tarsal index’. It is concluded that this optimization method provides the opportunity to incorporate inter-individual anatomical differences into kinematic and dynamic analysis of the ankle joint complex. This allows a more functional interpretation of kinematic data, and more realistic estimates of internal forces.     

Anatomy and Biomechanical Properties of the Plantar Aponeurosis: A Cadaveric Study

Objectives

To explore the anatomy of the plantar aponeurosis (PA) and its biomechanical effects on the first metatarsophalangeal (MTP) joint and foot arch.

Methods

Anatomic parameters (length, width and thickness of each central PA bundle and the main body of the central part) were measured in 8 cadaveric specimens. The ratios of the length and width of each bundle to the length and width of the central part were used to describe these bundles. Six cadaveric specimens were used to measure the range of motion of the first MTP joint before and after releasing the first bundle of the PA. Another 6 specimens were used to evaluate simulated static weight-bearing. Changes in foot arch height and plantar pressure were measured before and after dividing the first bundle.

Results

The average width and thickness of the origin of the central part at the calcaneal tubercle were 15.45 mm and 2.79 mm respectively. The ratio of the length of each bundle to the length of the central part was (from medial to lateral) 0.29, 0.30, 0.28, 0.25, and 0.27, respectively. Similarly, the ratio of the widths was 0.26, 0.25, 0.23, 0.19 and 0.17. The thickness of each bundle at the bifurcation of the PA into bundles was (from medial to lateral) 1.26 mm, 1.04 mm, 0.91 mm, 0.84 mm and 0.72 mm. The average dorsiflexion of the first MTP joint increased 10.16° after the first bundle was divided. Marked acute changes in the foot arch height and the plantar pressure were not observed after division.

Conclusions

The first PA bundle was not the longest, widest, or the thickest bundle. Releasing the first bundle increased the range of motion of the first MTP joint, but did not acutely change foot arch height or plantar pressure during static load testing.     

Biomechanics of the joints of the large toe. Shape and movement of the first tarsometatarsal joint and of the medial cuneonavicular joint]

90% of the first (hallucal) tarsometatarsal joints are screw-shaped; the axis is directed upwards to the front touching the lateral edge of the joint. Thus the plantar flexion is inevitably accompanied by an adduction and a pronation, and vice versa a dorsiflexion is consequently accompanied by an abduction and a supination, when the articular surfaces exactly slide along each other. 10% of these joints, however, are ellipsoid-shaped; in this case the distal articular surface of the medial cuneiform bone has the form of an ovoid head, and a strong ligament situated next to the lateral edge of the joint effects the same kind of motion described above. The medial cuneonavicular joint is always ellipsoid-shaped, the head of which is made up by the medial facet of the distal articular surface of the navicular bone. Each of the two joints mentioned has a considerable range of mobility.     

The association between patellar alignment on magnetic resonance imaging and radiographic manifestations of knee osteoarthritis

The aim of our study was to evaluate the association between patellar alignment by using magnetic resonance imaging images and radiographic manifestations of patello-femoral osteoarthritis (OA). Subjects were recruited to participate in a natural history study of symptomatic knee OA. We examined the relation of patellar alignment in the sagittal plane (patellar length ratio (PLR)) and the transverse plane (sulcus angle (SA), lateral patellar tilt angle (LPTA), and bisect offset (BO)) to radiographic features of patello-femoral OA, namely joint space narrowing and patellar osteophytes, using a proportional odds logistic regression model while adjusting for age, sex, and bone mass index (BMI). The study sample consisted of 126 males (average age 68.0 years, BMI 31.2) and 87 females (average age 64.7 years, BMI 31.6), 75% of whom had tibiofemoral OA (a Kellgren-Lawrence score of 2 or more). PLR showed a statistically significant association with joint space narrowing and osteophytosis in the lateral compartment. SA showed significant association with medial joint space narrowing and with lateral and medial patellar osteophytosis. LPTA and BO showed significant association with both radiographic indices of the lateral compartment. Clear linear trends were found in association between PLR, LPTA and BO, and with outcomes associated with lateral patello-femoral OA. SA, LPTA, and BO showed linear trends of association with medial joint space narrowing. Results of our study clearly suggest the association between indices of patellar alignment and such features of patello-femoral OA as osteophytosis and joint space narrowing. Additional studies will be required to establish the normal and abnormal ranges of patellar alignment indices and their longitudinal relation to patello-femoral OA.     

Analysis of the human and ape foot during bipedal standing with implications for the evolution of the foot

The ratio of the power arm (the distance from the heel to the talocrural joint) to the load arm (that from the talocrural joint to the distal head of the metatarsals), or RPL, differs markedly between the human and ape foot. The arches are relatively higher in the human foot in comparison with those in apes. This study evaluates the effect of these two differences on biomechanical effectiveness during bipedal standing, estimating the forces acting across the talocrural and tarsometatarsal joints, and attempts to identify which type of foot is optimal for bipedal standing. A simple model of the foot musculoskeletal system was built to represent the geometric and force relationships in the foot during bipedal standing, and measurements for a variety of human and ape feet applied. The results show that: (1) an RPL of around 40% (as is the case in the human foot) minimizes required muscle force at the talocrural joint; (2) the presence of an high arch in the human foot reduces forces in the plantar musculature and aponeurosis; and (3) the human foot has a lower total of force in joints and muscles than do the ape feet. These results indicate that the proportions of the human foot, and the height of the medial arch are indeed better optimized for bipedal standing than those of apes, further suggesting that their current state is to some extent the product of positive selection for enhanced bipedal standing during the evolution of the foot.     

A comparison of the influence of global functional loads vs. local contact anatomy on articular cartilage thickness at the knee

Cartilage contact geometry, along with joint loading, can play an important role in determining local articular cartilage tissue stress. Thus individual variations in cartilage thickness can be associated with both individual variations in joint loading associated with activities of daily living as well as individual differences in the anatomy of the contacting surfaces of the joint. The purpose of this study was to isolate the relationship between cartilage thickness predicted by individual variations in contact surface geometry based on the radii of the femur and tibia vs. cartilage thickness predicted by individual variations in joint loading. Knee magnetic resonance (MR) images and the peak knee adduction moments during walking were obtained from 11 young healthy male subjects (age 30.5+/-5.1 years). The cartilage thicknesses and surface radii of the femoral and tibial cartilage were measured in the weight-bearing regions of the medial and lateral compartments of three-dimensional models from the MR images. The ratio of contact pressure between the medial and lateral compartments was calculated from the radii of tibiofemoral contact surface geometries. The results showed that the medial to lateral pressure ratios were not correlated with the medial to lateral cartilage thickness ratios. However, in general, pressure was higher in the lateral than medial compartments and cartilage was thicker in the lateral than medial compartments. The peak knee adduction moment showed a significant positive linear correlation with medial to lateral thickness ratio in both femur (R(2)=0.43,P<0.01) and tibia (R(2)=0.32,P<0.01). The results of this study suggest that the dynamics of walking is an important factor to describe individual differences in cartilage thickness for normal subjects.     

Site specificity of mechanical and structural properties of human fascia lata and their gender differences: A cadaveric study

The whole thigh muscles are covered with the fascia lata, which could have morphological and mechanical features that match the underlying muscles’ functions. In this study, we investigated the morphological and elastic properties of the human fascia lata taken from four (anterior, medial, lateral, and posterior) sites on the thigh of 17 legs of 12 cadavers (6 males and 6 females, 75–92 years). The thickness of the fascia lata was determined with a caliper. The interwoven collagen fiber’s directions were measured and classified into longitudinal, transverse, and diagonal in two opposing directions, relative to the thigh. Tensile strength test along the longitudinal and transverse directions was performed, and the stiffness, Young’s modulus, and hysteresis were determined. Fascia lata at the lateral site (0.8 ± 0.2 mm) was significantly thicker compared to other sites (0.2–0.3 mm). Fiber’s directions showed substantial variability among sites, and longitudinally directed fibers were higher in proportion (28–32%) than those in other directions (20–27%) at all sites except for the posterior site. The stiffness and Young’s modulus in the longitudinal direction (20–283 N/mm; 71.6–275.9 MPa, highest at the lateral site) were significantly higher than in the transverse direction (3–16 N/mm; 3.2–41.9 MPa, lowest at the lateral site). At the medial site, the proportion of the transversely directed fibers was higher in females than males, with higher stiffness and Young’s modulus thereof. The present study shows that the fascia lata possesses site- and gender-dependence of the morphological characteristics and elastic properties.     

The effect on patellofemoral joint stability of selective cutting of lateral retinacular and capsular structures

Patient selection for lateral retinacular release (LRR) and its efficacy are controversial. Iatrogenic medial subluxation can occur with inappropriate LRR. The aim of this study was to determine the reduction in patellofemoral stability with progressively more extensive LRR. The force required to displace the patella 10 mm medially and laterally in nine cadaveric knees was measured with and without loading of the quadriceps and iliotibial band. The knee was tested intact, then after progressive release beginning proximal to the patella (PR), the mid-level between the proximal and distal limit of the patella (MR) where the fibres are more transverse, then distally till Gerdy's tubercle (DR) and finally the joint capsule (CR). Both medial and lateral stability decreased with progressive releases, larger for the medial. The MR caused a significant reduction of lateral stability between 30° and 90° of knee flexion. There was an 8% reduction in medial stability at 0° flexion with a complete LRR (DR). A comparable reduction in medial stability in the loaded knee at 20° and 30° flexion was obtained with MR alone, with no further reduction after DR. A capsular release caused a further reduction in medial stability at 0° and 20° and this was marked in the unloaded knee. In extension, the main lateral restraint was the joint capsule. At 30° flexion, the transverse fibres were the main contributor to the lateral restraint.     

Three-dimensional measurement of the occlusal surfaces of lower first molars of Australian aboriginals

The occlusal surfaces of lower first molars of Australian Aboriginals were measured in three dimensions with the aid of Moiré contourography. Molar cuspal heights in this population were higher than in Japanese (Mongoloid) but lower than in Dutch (Caucasoid) populations. Intercuspal distances were considerably larger than those in the two other populations. Populational differences in occlusal features may influence both craniofacial structures and jaw movements in the three populations. Low correlations between the cuspal heights and the intercuspal distances in the other two populations were also found in this population, indicating that human molar cuspal height is independent of the transverse size of the crown. Mean values for the height of the three principal cusps in lower first molars were less than those in upper ones. However, the height of the hypoconid, which was the highest in the lower molar cusps, showed almost the same mean value as the height of the upper three principal cusps, indicating that the height of the main functional cusp, in both upper and lower first molars, was almost the same.     

An ultrasound based non-invasive method for the measurement of intrinsic foot kinematics during gait

Soft tissue artefact (STA) and marker placement variability are sources of error when measuring the intrinsic kinematics of the foot. This study aims to demonstrate a non-invasive, combined ultrasound and motion capture (US/MC) technique to directly measure foot skeletal motion. The novel approach is compared to a standard motion capture protocol. Fourteen participants underwent instrumented barefoot analysis of foot motion during gait. Markers were attached to foot allowing medial longitudinal arch angle and navicular height to be determined. For the US/MC technique, the navicular marker was replaced by an ultrasound transducer which was secured to the foot allowing the skeletal landmark to be imaged. Ultrasound cineloops showing the location of the navicular tuberosity during the walking trials were synchronised with motion capture measurements and markers mounted on the probe allowed the true position of the bony landmark to be determined throughout stance phase. Two discrete variables, minimum navicular height and maximum MLA angle, were compared between the standard and US/MC protocols. Significant differences between minimum navicular height (P=0.004, 95% CI (1.57, 6.54)) and maximum medial longitudinal arch angle (P=0.0034, 95% CI (13.8, 3.4)) were found between the measurement methods. The individual effects of STA and marker placement error were also assessed. US/MC is a non-invasive technique which may help to provide more accurate measurements of intrinsic foot kinematics.     

Foot arch deformation and plantar fascia loading during running with rearfoot strike and forefoot strike: A dynamic finite element analysis

Forefoot strike becomes popular among runners because it facilitates better impact attenuation. However, forefoot strike may overload the plantar fascia and impose risk of plantar fasciitis. This study aimed to examine and compare the foot arch deformation and plantar fascia tension between different foot strike techniques in running using a computational modelling approach. A three-dimensional finite element foot model was reconstructed from the MRI of a healthy runner. The foot model included twenty bones, bulk soft tissue, ligaments, tendons, and plantar fascia. The time-series data of segmental kinematics, foot muscle force, and ankle joint reaction force were derived from a musculoskeletal model of the same participant based on the motion capture analysis and input as the boundary conditions for the finite element analysis. Rearfoot strike and forefoot strike running were simulated using a dynamic explicit solver. The results showed that, compared to rearfoot strike, forefoot strike reduced the foot arch height by 9.12% and increased the medial longitudinal arch angle by 2.06%. Forefoot strike also increased the plantar connective tissues stress by 18.28–200.11% and increased the plantar fascia tensile force by 18.71–109.10%. Although it is currently difficult to estimate the threshold value of stress or force that results in injury, forefoot strike runners appeared to be more vulnerable to plantar fasciitis.     

The Relationships between Foot Arch Volumes and Dynamic Plantar Pressure during Midstance of Walking in Preschool Children

Objectives

The purpose of this study was to examine the correlation between the foot arch volume measured from static positions and the plantar pressure distribution during walking.

Methods

A total of 27 children, two to six years of age, were included in this study. Measurements of static foot posture were obtained, including navicular height and foot arch volume in sitting and standing positions. Plantar pressure, force and contact areas under ten different regions of the foot were obtained during walking.

Results

The foot arch index was correlated (r = 0.32) with the pressure difference under the midfoot during the foot flat phase. The navicular heights and foot arch volumes in sitting and standing positions were correlated with the mean forces and pressures under the first (r = −0.296∼−0.355) and second metatarsals (r = −0.335∼−0.504) and midfoot (r = −0.331∼−0.496) during the stance phase of walking. The contact areas under the foot were correlated with the foot arch parameters, except for the area under the midfoot.

Conclusions

The foot arch index measured in a static position could be a functional index to predict the dynamic foot functions when walking. The foot arch is a factor which will influence the pressure distribution under the foot. Children with a lower foot arch demonstrated higher mean pressure and force under the medial forefoot and midfoot, and lower contact areas under the foot, except for the midfoot region. Therefore, children with flatfoot may shift their body weight to a more medial foot position when walking, and could be at a higher risk of soft tissue injury in this area.     

The Jinniushan hominin pedal skeleton from the late Middle Pleistocene of China

Bipedalism has long been recognized as the seminal adaptation of the hominin radiation and thus used to distinguish hominins from great ape fossils. Notwithstanding preconceptions and varied interpretations, the distinctive features of the modern human foot and accompanying striding gait, appear to be recent innovations that are largely absent in the earliest facultative bipeds. These distinctive features are mainly components of fixed longitudinal and transverse pedal arches, and of a uniquely derived hallucal metatarsophalangeal joint. They enhance ankle joint plantar flexor function and accommodate localized peak plantar pressures at the medial ball during terminal stance. To date, the paleontological record has yielded very little of the hominin foot, especially of the Middle Pleistocene hominins. New specimens from this time interval should help provide insights into the timing and pattern of what appears to be a mosaic pattern of evolution of the modern human foot features. Here we describe the fossil hominin foot skeleton recovered from the Jinniushan site, Liaoning Province, People's Republic of China. It affords a singular glimpse of the pedal morphology of a late Middle Pleistocene hominin (c.f. Homo heidlebergensis). Dated to 200 ka or older, this foot offers the earliest evidence for increased stability of the medial longitudinal arch, while retaining a number of primitive features apparently characteristic of robust premodern hominins, including lower arches and a less stable hallucal metatarsophalangeal joint (medial ball) than in modern humans. These features reflect different foot capabilities and suggest the bipedal stride of the Jinniushan hominin differed subtlety from that of modern humans.     

Effect of simulated joint instability and bracing on ankle and subtalar joint flexibility

It is clinically challenging to distinguish between ankle and subtalar joints instability in vivo. Understanding the changes in load-displacement at the ankle and subtalar joints after ligament injuries may detect specific changes in joint characteristics that cannot be detected by investigating changes in range of motion alone. The effect of restricting joints end range of motion with ankle braces was already established, but little is known about the effect of an ankle brace on the flexibility of the injured ankle and subtalar joints. Therefore, the purposes of this study were to (1) understand how flexibility is affected at the ankle and subtalar joints after sectioning lateral and intrinsic ligaments during combined sagittal foot position and inversion and during internal rotation and (2) investigate the effect of a semi-rigid ankle brace on the ankle and subtalar joint flexibility. Kinematics and kinetics were collected from nine cadaver feet during inversion through the range of ankle flexion and during internal rotation. Motion was applied with and without a brace on an intact foot and after sequentially sectioning the calcaneofibular ligament (CFL) and the intrinsic ligaments. Segmental flexibility was defined as the slope of the angle-moment curve for each 1 Nm interval. Early flexibility significantly increased at the ankle and subtalar joint after CFL sectioning during inversion. The semi-rigid ankle brace significantly decreased early flexibility at the subtalar joint during inversion and internal rotation for all ligament conditions and at the ankle joint after all ligaments were cut.     

In vivo tests of an improved method for functional location of the subtalar joint axis

The subtalar joint is important in frontal plane movement and posture of the hindfoot. Abnormal subtalar joint moments caused by muscle forces and the ground reaction force acting on the foot are thought to play a role in various foot deformities. Calculating joint moments typically requires knowledge of the location of the joint axis; however, location of the subtalar axis from measured movement is difficult because the talus cannot be tracked using skin-mounted markers. The accuracy of a novel technique for locating the subtalar axis was assessed in vivo using magnetic resonance imaging. The method was also tested with skin-mounted markers and video motion analysis. The technique involves applying forces to the foot that cause pure subtalar joint motion (with negligible talocrural joint motion), and then using helical axis decomposition of the resulting tibiocalcaneal motion. The resulting subtalar axis estimates differed by 6° on average from the true best-fit subtalar axes in the MRI tests. Motion was found to have been applied primarily about the subtalar joint with an average of only 3° of talocrural joint motion. The proposed method provides a potential means for obtaining subject-specific subtalar axis estimates which can then be used in inverse dynamic analyses and subject-specific musculoskeletal models.     

Biomechanical analysis of foot with different foot arch heights: a finite element analysis

Clinically, different foot arch heights are associated with different tissue injuries to the foot. To investigate the possible factors contributing to the difference in foot arch heights, previous studies have mostly measured foot pressure in either low-arched or high-arched feet. However, little information exists on stress variation inside the foot with different arch heights. Therefore, this study aimed to implement the finite element (FE) method to analyse the influence of different foot arches. This study established a 3D foot FE model using software ANSYS 11.0. After validating the FE model, this study created low-arched, high-arched and normal-arched foot FE models. The FE analysis found that both the stress and strain on the plantar fascia and metatarsal were higher in the high-arched foot, whereas the stress and strain on the calcaneous, navicular and cuboid were higher in low-arched foot. Additionally, forefoot pressure was increased with an increase in arch height.     

Biomechanical analysis of foot with different foot arch heights: a finite element analysis

Clinically, different foot arch heights are associated with different tissue injuries to the foot. To investigate the possible factors contributing to the difference in foot arch heights, previous studies have mostly measured foot pressure in either low-arched or high-arched feet. However, little information exists on stress variation inside the foot with different arch heights. Therefore, this study aimed to implement the finite element (FE) method to analyse the influence of different foot arches. This study established a 3D foot FE model using software ANSYS 11.0. After validating the FE model, this study created low-arched, high-arched and normal-arched foot FE models. The FE analysis found that both the stress and strain on the plantar fascia and metatarsal were higher in the high-arched foot, whereas the stress and strain on the calcaneous, navicular and cuboid were higher in low-arched foot. Additionally, forefoot pressure was increased with an increase in arch height.