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A prospective biomechanical study of the association between foot pronation and the incidence of anterior knee pain among military recruits. J Bone Joint Surg Br. 2006 Jul;88(7):905-8
Quote:
Excessive foot pronation has been considered to be related to anterior knee pain. We undertook a prospective study to test the hypothesis that exertional anterior knee pain is related to the static and dynamic parameters of foot pronation. Two weeks before beginning basic training lasting for 14 weeks, 473 infantry recruits were enrolled into the study and underwent two-dimensional measurement of their subtalar joint displacement angle during walking on a treadmill. Of the 405 soldiers who finished the training 61 (15%) developed exertional anterior knee pain. No consistent association was found between the incidence of anterior knee pain and any of the parameters of foot pronation. While a statistically significant association was found between anterior knee pain and pronation velocity (left foot, p = 0.05; right foot, p = 0.007), the relationship was contradictory for the right and left foot. Our study does not support the hypothesis that anterior knee pain is related to excessive foot pronation.
This older study is consistent with the above finding: Comparison of foot pronation and lower extremity rotation in persons with and without patellofemoral pain.
Foot Ankle Int. 2002 Jul;23(7):634-40
Quote:
Abnormal foot pronation and subsequent rotation of the lower extremity has been hypothesized as being contributory to patellofemoral pain (PFP). The purpose of this study was to test the hypothesis that subjects with PFP would exhibit larger degrees of foot pronation, tibia internal rotation, and femoral internal rotation compared to individuals without PFP. Twenty-four female subjects with a diagnosis of PFP and 17 female subjects without PFP participated. Three-dimensional kinematics of the foot, tibia, and femur segments were recorded during self-selected free-walking trials using a six-camera motion analysis system (VICON). No group differences were found with respect to the magnitude and timing of peak foot pronation and tibia rotation. However, the PFP group demonstrated significantly less femur internal rotation compared the comparison group. These results do not support the hypothesis that individuals with PFP demonstrate excessive foot pronation or tibial internal rotation compared to nonpainful individuals. The finding of decreased internal rotation in the PFP group suggests that this motion may be a compensatory strategy to reduce the quadriceps angle.
No doubt clinically, that addressing biomechanical foot issues often assists anterior knee pain. I should add, that low-dye taping, for instance, can often predict whether it there is a 'connection' for that particular patient, and that particular problem.
Last edited by Atlas : 27th June 2006 at 06:58 PM.
Relationship Between Static Posture and Rearfoot Motion During Walking in
Patellofemoral Pain Syndrome: Effect of a Reference Posture for Gait
Analysis J Am Podiatr Med Assoc 96(4): 323–329, 2006
Quote:
The reference posture used in angular motion calculations may play an important role in the relationship found between static posture and rearfoot motion in the frontal plane in a clinical population such as patients with patellofemoral pain syndrome. This study examined the relationship between rearfoot inversion and eversion during the stance phase of walking and the static relaxed standing measurement in women (aged 18 years and older) with patellofemoral pain syndrome and controls and examined the influence of the reference posture used when calculating dynamic motion. Two reference postures were investigated: vertical alignment between the rearfoot and the lower leg and relaxed calcaneal standing. When using the latter reference posture, a significant correlation was found between the static relaxed standing measurement and peak eversion in controls only. When using the vertical alignment reference posture, significant correlation was found only in the patellofemoral pain syndrome group for peak eversion and inversion. The positive relationship found in the patellofemoral pain syndrome group between dynamic angular measures, based on a neutral reference posture, and static relaxed standing indicated that for subjects with patellofemoral pain syndrome, the clinical rearfoot measurement of relaxed standing can be used to explain the pattern of rearfoot motion during walking.
A Prospective Study on Gait-related Intrinsic Risk Factors for Patellofemoral Pain.
Thijs Y, Tiggelen DV, Roosen P, Clercq DD, Witvrouw E. Clin J Sport Med. 2007 Nov;17(6):437-445.
Quote:
OBJECTIVE:: To prospectively determine gait-related risk factors for patellofemoral pain. DESIGN:: A prospective cohort study. SETTING:: Male and female recruits of the Belgian Royal Military Academy during a 6-week basic military training period. PARTICIPANTS:: Eighty-four officer cadets (65 men, 19 women), who entered the Military Academy and were without a history of any knee or lower-leg complaints, participated in the study. INTERVENTIONS:: Before the start of the 6-week basic military training period, plantar pressure measurements during walking were performed. During the basic military training period, patellofemoral complaints were diagnosed and registered by a sports medicine physician. MAIN OUTCOME MEASUREMENTS:: Plantar pressure measurements during walking were performed using a footscan pressure plate (RsScan International).
RESULTS:: During the 6-week training period, 36 subjects developed patellofemoral pain (25 male and 11 female). Logistic regression analysis revealed that subjects who developed patellofemoral pain had a significantly more laterally directed pressure distribution at initial contact of the foot, a significantly shorter time to maximal pressure on the fourth metatarsal, and a significantly slower maximal velocity of the change in lateromedial direction of the center of pressure during the forefoot contact phase.
CONCLUSIONS:: Our findings suggest that the feet of the persons who developed anterior knee pain have a heel strike in a less pronated position and roll over more on the lateral side compared with the control group. The results of this study can be considered valuable in identifying persons at risk for patellofemoral pain.
If I am understanding this correctly, then I would tend to agree from the clinical data I have collected.
I tend to see anterior knee pain in patients with a LLD, short, on the same limb, or an early knee flexion on that side.
The early knee flexion can be on the long limb side, if that is the selected compensation for the opposite limb being short.
The early knee flexion can also be on teh short limb side if the MTJ is stable and the patient has AJE. If the AJE cannot be compensated for at the MTJ, the next joint to go is usually the knee.
I would consider the observation that the heel strike is in a less pronated position and the foot rolling over more on the lateral side to be a supinated foot position compensation regularly seen in AJE or short side LLD compensations.
Do you have a full copy Admin??? You know I love you! ;-)
Sorry I'll miss you in San Diego. Drink one for me as I'll be thinking of you all!
Bruce
The paradox:
1. Clinically we use foot orthoses to treat rearfoot pronation to help patellofemoral pain syndrome
2. Two RCT's with OK methodology show that when we do that, they help (ie Eng et al 1993; and another big good one from U of Q, thats still coming, but we got a glimpse of the results at SMA mtg)
3. The cross sectional and prospective studies (see above) are not showing a link between rearfoot pronation and patellofemoral pain
4. Don't figure
(Bruce - Check your email)
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
Last edited by Craig Payne : 13th November 2007 at 02:58 PM.
The paradox:
1. Clinically we use foot orthoses to treat rearfoot pronation to help patellofemoral pain syndrome
2. Two RCT's with OK methodology show that when we do that, they help (ie Eng et al 1993; and another big good one from U of Q, thats still coming, but we got a glimpse of the results at SMA mtg)
3. The cross sectional and prospective studies (see above) are not showing a link between rearfoot pronation and patellofemoral pain
4. Don't figure
(Bruce - Check your email)
Thanks for the papers Craig. I see why you are confused re: historical teachings and past study results. But, from what I see with in-shoe pressure data, they are exactly right.
The faster peak loading of the 4th mpj would indicate to me early heel loss of pressure meaning short limb side and or AJE and a supinated foot strike and positioning.
This is futher confirmed to me by the lateral heel stike and prolonged lateral CoP.
Finally, don't discount pronation in the above equation. Just because a foot has AJE and / or LLD short, and may appear to supinate from contact to early midstance does not mean that there is not late midstance prolonged pronation in effect! The study states that there was a large delay in the PFP group moving the CoP from lateral to medial in the forefoot. AJE and / or LLD will lead to a weakness of the Peroneals as Howard has shown in his papers. That will in turn lead to FnHL and potential over action of the supinatory muscles such as the Anterior Tibialis and Posterior tibialis.
So, don't despair. There is still late midstance pronation in that final study, but the LLD / AJE is just as important to address, if not more so!
Great posts!:)
The faster peak loading of the 4th mpj would indicate to me early heel loss of pressure meaning short limb side and or AJE and a supinated foot strike and positioning.
This is futher confirmed to me by the lateral heel stike and prolonged lateral CoP.
Bruce, I see you are using the F-Scan to determine leg length, but aren't you determing functional leg length? Do you correlate your finding with a postural exam, and if so which ones. I ask this so that everyone who reads your posts will be on the same page with you.
Quote:
Originally Posted by Bruce Williams
Finally, don't discount pronation in the above equation. Just because a foot has AJE and / or LLD short, and may appear to supinate from contact to early midstance does not mean that there is not late midstance prolonged pronation in effect! .
Good point. Clinically, when you see a patient with medial and lateral pathology (supinatory and pronatory), then you know it is a short leg with equinus.
Quote:
Originally Posted by Bruce Williams
but the LLD / AJE is just as important to address, if not more so!
36 recruits out of 84 got PFJ pain....
I would say a high risk factor would be doing officier training in Belgium!
I would say they have to look at the training and footwear...
__________________
Craig Tanner
Podiatrist ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR http://www.aspetar.com/
What is rearfoot prontation and how do you diagnose it?
Musmed
Quote:
Originally Posted by Craig Payne
The paradox:
1. Clinically we use foot orthoses to treat rearfoot pronation to help patellofemoral pain syndrome
2. Two RCT's with OK methodology show that when we do that, they help (ie Eng et al 1993; and another big good one from U of Q, thats still coming, but we got a glimpse of the results at SMA mtg)
3. The cross sectional and prospective studies (see above) are not showing a link between rearfoot pronation and patellofemoral pain
4. Don't figure
What is rearfoot prontation and how do you diagnose it?
I was refering to the studies above - each used a different measure of "pronation".
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
Bruce, I see you are using the F-Scan to determine leg length, but aren't you determing functional leg length? Do you correlate your finding with a postural exam, and if so which ones. I ask this so that everyone who reads your posts will be on the same page with you.
Regards,
Stanley
Stanley;
I assess for LLD by checking the ASIS and PSIS in stance. I will have the patients stand in RCSP an NCSP as well to see if the pelvis attempts to balance.
I also check for Peroneal weakness and AJE one side more than another.
I also will check for shoulder height comparison, watch for one arm swinging more than another, check to see if one foot is pronating more than the other on stance, etc.
I don't put a lot of stock into a difference between functional and structrural LLD. The body will functionally adapt for either one and you need to be able to identify the problem, no matter the cause, to treat it.
I know many people disagree with me on this, but no matter what you do for core strengthening, manipulations, AK, etc, if the foot continues to adapt and cannot hold the changes you want it will always revert to what it was doing before.
This I can see on F-scan and that is why I treat most of these from the ground up. ONce the prescription is correct in the orthosis, you won't need to manipulate anymore and the strength will return to the peroneals, etc.
MMMMAAAATTTEEEEEE
I am still in the dark.
what studies and where can I see them.
overpronated and underloved!
musmed
Every cross-sectional study that has looked at the prevalance of "pronated" feet in those with and without patellofemoral pain have found no differences (eg Comparison of foot pronation and lower extremity rotation in persons with and without patellofemoral pain. Foot Ankle Int. 2002 Jul;23(7):634-40) and every prospective study of risk factors for patellofemoral pain found that a "pronated" foot did not increase the risk (there are a few more than the couple of abstracts posted above in this thread; eg A Prospective Study on Gait-related Intrinsic Risk Factors for Patellofemoral Pain. Thijs Y, Tiggelen DV, Roosen P, Clercq DD, Witvrouw E. Clin J Sport Med. 2007 Nov;17(6):437-445.).
We could debate what the exact measure each study used to determine "pronation" (we could have a whole thread on this).
The point I am trying to make is that we have all this data showing no relationship between foot "pronation" and patellofemoral pain, yet we have 2 good RCT's (one published and one coming) that show when you use foot orthoses to treat rearfoot "pronation" in those with patellofemoral pain, then they get beater ....don't figure
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
The point I am trying to make is that we have all this data showing no relationship between foot "pronation" and patellofemoral pain, yet we have 2 good RCT's (one published and one coming) that show when you use foot orthoses to treat rearfoot "pronation" in those with patellofemoral pain, then they get beater ....don't figure
Craig,
I agree with this. In 1980, I had Professor Karl Klein lecture at a seminar. Afterwards, I disussed Chondromalacia and pronation with him. He said “pronation increases the Q angle” and he demonstrated it. He sat down with his feet on the ground and adducted his femur. Sure enough, the tibial tuberosity moved relatively laterally. It took me time looking at this and knowing that pronation internally rotates the tibia to realize that what he showed me was not pronation, but rather a knee movement which consists of external rotation and abduction of the tibia. When the knee compensates we get knee pathology, and when the subtalar joint compensates we get overuse of the posterior tibial muscle/tendon or sinus tarsitis.
Orthoses work by stopping the need to compensate at either joint.
I hope this clears it up.
Every cross-sectional study that has looked at the prevalance of "pronated" feet in those with and without patellofemoral pain have found no differences (eg Comparison of foot pronation and lower extremity rotation in persons with and without patellofemoral pain. Foot Ankle Int. 2002 Jul;23(7):634-40) and every prospective study of risk factors for patellofemoral pain found that a "pronated" foot did not increase the risk (there are a few more than the couple of abstracts posted above in this thread; eg A Prospective Study on Gait-related Intrinsic Risk Factors for Patellofemoral Pain. Thijs Y, Tiggelen DV, Roosen P, Clercq DD, Witvrouw E. Clin J Sport Med. 2007 Nov;17(6):437-445.).
We could debate what the exact measure each study used to determine "pronation" (we could have a whole thread on this).
The point I am trying to make is that we have all this data showing no relationship between foot "pronation" and patellofemoral pain, yet we have 2 good RCT's (one published and one coming) that show when you use foot orthoses to treat rearfoot "pronation" in those with patellofemoral pain, then they get beater ....don't figure
Craig
Still Lost... What is rearfoot pronation and how do you diagnose it,or measure it, or what ever, is the good eye ball look the owner of the information?
The point I am trying to make is that we have all this data showing no relationship between foot "pronation" and patellofemoral pain, yet we have 2 good RCT's (one published and one coming) that show when you use foot orthoses to treat rearfoot "pronation" in those with patellofemoral pain, then they get beater ....don't figure
Hi Graig,
Would you happen to have the name of the RCT (and where this can be accessed) that has already been published regarding what you were mentioning about treating RF pronation and PFP improvement?
Would you happen to have the name of the RCT (and where this can be accessed) that has already been published regarding what you were mentioning about treating RF pronation and PFP improvement?
The publicshed RCT with methodology that is ok is this one:
The effect of soft foot orthotics on three-dimensional lower-limb kinematics during walking and running JJ Eng and MR Pierrynowski PHYS THER Vol. 74, No. 9, September 1994, pp. 836-844
The other good and big one is Bill Vicenzino's that is still being analysed, but we got a look at early data from Bill a month ago and the orthotics were better than placebo.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
The publicshed RCT with methodology that is ok is this one:
The effect of soft foot orthotics on three-dimensional lower-limb kinematics during walking and running JJ Eng and MR Pierrynowski PHYS THER Vol. 74, No. 9, September 1994, pp. 836-844
The other good and big one is Bill Vicenzino's that is still being analysed, but we got a look at early data from Bill a month ago and the orthotics were better than placebo.
Thanks for that Graig.
Despite the studies you have suggested, what are your current thoughts on the reasearch carried by Beno M. Nigg re: Shoe & Orthotics Knee Joint Loading (2007)? From my understading, the study made mention that there was no real difference between PFO's and OTC orthotics. Furthermore, it also concluded that, with orthotic intervention, Knee moments are often increased, results are unexected and are generally not systematic.
I haven't read the article below you suggested yet, however, what would they have done differently from Beno M. Nigg's reasearch to suggest that their are improvments in PFPS, with treating RF pronation (using soft orthotics)?
Beno Nigg and a lot of others have done a lot of kinematic and kinetic work on the effects of foot orthoses on knee joint mechanics. NONE of the changes described by those studies have yet been linked to outcomes.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
NONE of the changes described by those studies have yet been linked to outcomes.
Graig, I would appreciate it if you could just elborate a little further.
Beno Nigg's research also discusses he concept of muscle tuning, and emphasises the importance of "strong small muscles" to reduce joint pain, increase joint stability and reduce joint loading. Basically, he suggests that another solution or alternative to the treatment of PFPS, is to train and strengthen the smaller intrinsic muscles.
There is plenty of documentation on what different sorts of foot orthotics do to different kinematic and kinetic parameters (eg as you mentioned, Nigg showed the changes in frontal plane knee moments; other have shown changes in hip motion; other have shown changes in tibial rotation; etc etc) .... but they are all based in the lab. For patellofemoral pain, we have absolutly no idea which of the kinematic and kinetic parameters are important to change in order to get a good clinical outcome. We have some good ideas what might be important, but they remain untested.
I am familiar with Nigg's muscle tuning concepts (in fact I was just writing about it in a powerpoint as I got the email about your message just posted). It is an interesting concept and he is probably right, and the period of "instability" he advocates may well increase joint stability and he has shown it can reduce joint loading. BUT, just like the kinematic and kinetic stuff, we have no idea if a change any of those parameters actually affects clinical outcome.
This has been quite a bit of discussion on this today at PFOLA.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
Craig;
I'm certain you have this paper as well. I thought the abstract might be interesting for others. It seems to confirm the kinematic findings of the paper that started this discussion. I find it confirmatory for a lot of what I see in-shoe as well.
Relationship Between the Subtalar Joint Inclination Angle and the Location of Lower-Extremity Injuries
Michael R. Pierrynowski, PhD *, Eric Finstad, BHSc(PT) *, Marta Kemecsey, BHSc(PT) * and Jade Simpson, BHSc(PT) *
* Human Movement Laboratory, School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada.
Corresponding author: Michael R. Pierrynowski, PhD, Human Movement Laboratory, School of Rehabilitation Science, McMaster University, 1400 Main St W, Hamilton, Ontario, Canada L8S 1C7.
Abstract
This study hypothesized that individuals who have a history of knee pain during repetitive weightbearing activities have a higher subtalar joint inclination angle than those with a history of foot pain. Study participants were selected on the basis of results of a written questionnaire that asked about the site and cause of injury and pain frequency and intensity. Pain items were graded on a 7-point Likert scale. Subjects were mainly young (18 to 32 years of age), healthy university students who had a history of knee pain (knee group) or foot pain (foot group) during weightbearing activity. Both foot and lower-leg kinematic data were used to estimate the magnitude of each participant’s subtalar joint inclination angle. These data were obtained while participants performed a series of open- and closed-kinetic-chain motions. The subtalar joint inclination angle was significantly greater for the knee group than for the foot group. The results of this study support the hypothesis that a higher subtalar joint inclination angle may predispose an individual to knee pain, and a lower subtalar joint inclination angle to foot pain. (J Am Podiatr Med Assoc 93(6): 481-484, 2003)
The point I am trying to make is that we have all this data showing no relationship between foot "pronation" and patellofemoral pain, yet we have 2 good RCT's (one published and one coming) that show when you use foot orthoses to treat rearfoot "pronation" in those with patellofemoral pain, then they get beater ....don't figure
Absolutely agree.
My weekend reading leads me pose this: Is it possible, however, that the statistical phenomenon known as 'regression to the mean' could partly explain this?
For example, take a patient who presents with patellofemoral pain (or indeed any condition that causes pain for that matter). Simply stated, regression to the mean says that a person who scores at the extreme end of a scale (pain scale in this case), will, for statistical reasons, score much less extremely the next time they are measured.
This is where the level of detail in the RCT methodology is crucial: inparticular, mention of how long each subject in the trial had been suffering with patellofemoral pain, which may give some indication of the likely future course of the condition. In conducting an RCT should the subjects be asked "is the pain you are suffering now, the worst it has ever been?". If a large section of potential subjects answer 'yes', does this skew the results??
Maybe if If we give orthoses to a patient when their pain is at its worst, then plausibly, really the only way for the pain level to go is to reduce, or at worst, stay the same.
Don't get me wrong: I am happy to provide properly designed orthoses for knee pain and many other painful conditions of the lower limb where appropriate, but would be interested in the Arena's view on this. Does it explain the gap that C.P descibes between the research and clinical experience?
My two cents worth-just playing devil's advocate!!
__________________
Kind regards
Gavin Wylie
Podiatrist (Paediatrics),
Perth Royal Infirmary,
Perth, UK
Last edited by gavw : 19th November 2007 at 05:30 AM.
Reason: for reasons of clarity
Craig;
I'm certain you have this paper as well. I thought the abstract might be interesting for others. It seems to confirm the kinematic findings of the paper that started this discussion. I find it confirmatory for a lot of what I see in-shoe as well.
Relationship Between the Subtalar Joint Inclination Angle and the Location of Lower-Extremity Injuries
Michael R. Pierrynowski, PhD *, Eric Finstad, BHSc(PT) *, Marta Kemecsey, BHSc(PT) * and Jade Simpson, BHSc(PT) *
* Human Movement Laboratory, School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada.
Corresponding author: Michael R. Pierrynowski, PhD, Human Movement Laboratory, School of Rehabilitation Science, McMaster University, 1400 Main St W, Hamilton, Ontario, Canada L8S 1C7.
Abstract
This study hypothesized that individuals who have a history of knee pain during repetitive weightbearing activities have a higher subtalar joint inclination angle than those with a history of foot pain. Study participants were selected on the basis of results of a written questionnaire that asked about the site and cause of injury and pain frequency and intensity. Pain items were graded on a 7-point Likert scale. Subjects were mainly young (18 to 32 years of age), healthy university students who had a history of knee pain (knee group) or foot pain (foot group) during weightbearing activity. Both foot and lower-leg kinematic data were used to estimate the magnitude of each participant’s subtalar joint inclination angle. These data were obtained while participants performed a series of open- and closed-kinetic-chain motions. The subtalar joint inclination angle was significantly greater for the knee group than for the foot group. The results of this study support the hypothesis that a higher subtalar joint inclination angle may predispose an individual to knee pain, and a lower subtalar joint inclination angle to foot pain. (J Am Podiatr Med Assoc 93(6): 481-484, 2003)
Dear Bruce
How does one measure this subtalar joint inclination angle?
How does one measure this subtalar joint inclination angle?
Thanks in advance
Paul C.
Paul;
I don't have my radiology text with me at present. The talar declination angle and the calcaneal inclinaiton angle may be a combination of this. I cannot recall at this moment.
These are quotes from the paper.
The subtalar joint is formed by separate articulations
between the talus superiorly and the calcaneus inferiorly.
1 Although the motion between the talus and
calcaneus is complex,2 it typically has been considered
a uniaxial joint with pronation and supination
movements about the subtalar joint axis.3 There have
been many attempts to locate the subtalar joint axis
within a person’s foot using this mechanical linkage
model. The cadaver studies of Inman4 have been widely
cited to suggest that the mean ± SD subtalar joint
inclination angle relative to horizontal is 42° ± 9°,
with lower and upper bounds of 20.5° and 68.5°.The most accepted estimate of average subtalar
joint inclination angle (42°) results in an approximately
equal amount of frontal plane foot rotation
(inversion/eversion) and lower-leg transverse plane
rotation (external/internal). If a person has a lower
subtalar joint inclination angle, more inversion/eversion
foot rotation is associated with a fixed amount
of external/internal lower-leg rotation. Conversely, a
person with a high subtalar joint inclination angle
has more lower-leg transverse plane rotation than
frontal plane foot rotation.1 As a result of the mechanical
relationship between the subtalar joint inclination
angle and motion characteristics of the foot
and lower leg (the “mitred-hinge” response),4 it has
been postulated that a higher subtalar joint inclination
angle predisposes an individual to knee injuries
whereas a lower subtalar joint inclination angle pre-
Relationship Between the Subtalar
Joint Inclination Angle and the
Location of Lower-Extremity Injuries
This study hypothesized that individuals who have a history of knee pain
during repetitive weightbearing activities have a higher subtalar joint inclination
angle than those with a history of foot pain. Study participants
were selected on the basis of results of a written questionnaire that
asked about the site and cause of injury and pain frequency and intensity.
Pain items were graded on a 7-point Likert scale. Subjects were mainly
young (18 to 32 years of age), healthy university students who had a history
of knee pain (knee group) or foot pain (foot group) during weightbearing
activity. Both foot and lower-leg kinematic data were used to estimate
the magnitude of each participant’s subtalar joint inclination angle.
These data were obtained while participants performed a series of openand
closed-kinetic-chain motions. The subtalar joint inclination angle was
significantly greater for the knee group than for the foot group. The results
of this study support the hypothesis that a higher subtalar joint inclination
angle may predispose an individual to knee pain, and a lower subtalar
joint inclination angle to foot pain.
The subtalar joint inclination angle was estimated
using a modification of the van den Bogert et al3 protocol,
which has been shown to be reliable with a reported
0.7° intrasubject standard error of measurement
(SEM). Although this intrasubject SEM is small
compared with the mean group difference (knee –
foot = 7.1°), the intrasubject SEM was improved in
this study by averaging each participant’s right and
left foot subtalar joint inclination angles, measured
twice. Theoretically, the SEM of the subtalar joint inclination
angle for all of the participants should be
near 0.4° (van den Bogert’s value divided by the
square root of four measures), a value that allows us
to confidently state that the knee group participants
had higher subtalar joint inclination angles than the
foot group participants.
There are several limitations to the subtalar joint
inclination angle measurement protocol of van den
Bogert et al.3
Does not seem overly exact to me, but then that was not my point in referenceing this text. My point being that knee pain is more often associated with the less pronated foot that tends towards a short limb and AJE.
How does one measure this subtalar joint inclination angle?
Thanks in advance
Paul C.
Hi Paul,
This measurement can usually be determined by referring to a plain lateral view radiograph. You then bisect the head and neck of the talus and then measure the angle in relation to the supporting surface.
Foot pronation and knee pain
Linear Mode
