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Neale's Disorders of the Foot

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Authors: Paul Frowen Maureen O'Donnell J. Gordon Burrow

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Neale’s Disorders of the Foot remains the essential resource for students and practitioners
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reviewed and their diagnoses and management described along with areas of related
therapeutics. Students will find in this one volume everything they need to know about foot
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 Chapter
Structure and function of the foot
James Watkins
CHAPTER CONTENTS
Introduction 387
Skeleton of the foot 387
Movements of the ankle and foot 388
Ankle joint 388
Subtalar joint 389
Pronation and supination 389
Arches of the feet 390
Passive arch support 390
Active arch support 392
Interaction of the arch support mechanisms 392
The windlass mechanism of the foot 392
Structural adaptation of the musculoskeletal
System 393
Structural adaptation in bone 394
The chondral modelling phenomenon 394
Modelling of metaphyses and epiphyses 394
Modelling of articular surfaces 394
References 395
KEYWORDS
Ankle joint
Arch support mechanisms
Midtarsal joint
Modelling
Pronation
Rearfoot complex
Structural adaptation
Subtalar joint
Supination
Windlass
15 
INTRODUCTION
The main function of the foot is to transmit loads between the lower
leg and the ground. In static and, in particular, dynamic situations,
such as walking, running, jumping, and landing, the foot is subjected
to large loads, which, unless effectively transmitted, would be likely
to excessively overload not only the foot but also other parts of the
musculoskeletal system (Watkins 1999).
In dynamic situations the foot is required to act as both a shock
absorber, to cushion the impact of contact of the foot with the ground,
and as a propulsive mechanism to propel the body in the desired
direction (Blackwood et al 2005). The foot often performs these func-
tions on a variety of support surfaces. Whereas floor surfaces tend to
be firm and level, there are many other situations, such as in cross-
country running, where the surface of the ground is neither firm nor
level, but continually changes in terms of slope, evenness and hard-
ness. The ability of the foot to function effectively in relation to such
diverse environmental constraints is due to its structure, in particular
to its arched shape and complex movement capability.
SKELETON OF THE FOOT
The foot consists of 7 tarsals, 5 metatarsals and 14 phalanges (Fig.
15.1). The tarsals constitute the tarsus, which forms the rear part of
the foot. The foot articulates with the lower leg at the ankle joint
(talocrural joint), i.e. the joint between the tibia, fibula and talus. The
talus, the second largest tarsal, has a convex pulley-shaped articular
surface on its superior aspect, called the trochlear surface of the talus,
that articulates with the trochlear surface of the tibia. The trochlear
surface of the talus is continuous with articular surfaces on its lateral
and medial aspects that articulate with the lateral malleolus and
medial malleolus, respectively.
The inferior aspect of the talus articulates with the anterior half of
the superior aspect of the calcaneus by means of two or, in some cases,
three articular facets, which together constitute the subtalar joint (talo-
calcaneal joint). The anterior aspect (head) of the talus articulates with
387
 Neale’s Disorders of the Foot
Tibia
Talus
Navicular
First cuneiform
First metatarsal
Phalanges
A Cuneiforms
Fibula
Tibia
Talus
Navicular
Second and third
cuneiforms
Metatarsals
Calcaneus Cuboid
B
Figure 15.1  The bones of the right foot. (A) Medial aspect. (B) Lateral aspect. (C) Superior aspect.
the posterior aspect of the navicular, on the medial aspect of the foot,
to form the talonavicular joint. The anterior aspect of the calcaneus
articulates with the posterior aspect of the cuboid, on the lateral aspect
of the foot, to form the calcaneocuboid joint. The calcaneocuboid and
talonavicular joints are continuous with each other and constitute the
midtarsal joint, also referred to as the transverse tarsal joint (Czerniecki
1988). The anterior aspect of the navicular articulates with the poste-
rior aspects of the three cuneiforms (medial, middle, lateral), which
lie side by side and articulate with each other. The posterior two-thirds
of the lateral aspect of the lateral cuneiform articulate with the medial
surface of the cuboid. The anterior aspects of the medial, middle and
lateral cuneiforms articulate with the bases of the first, second and
third metatarsals, respectively. The anterior aspect of the cuboid artic-
ulates with the bases of the fourth and fifth metatarsals. The joints
between the four anterior tarsals and the metatarsals are referred to as
the tarsometatarsal joints. The lateral four metatarsals are similar in
length, but tend to increase in girth from the second to the fifth. In
comparison, the first metatarsal is usually shorter, but has a greater
girth than the other four. The metatarsals are collectively referred to
as the metatarsus. The heads of the metatarsals articulate with the
proximal phalanges of the toes to form the metatarsophalangeal
joints. The great toe (also referred to as the big toe or the hallux) is
composed of two phalanges and each of the other toes is composed
of three phalanges. The phalanges of the toes become progressively
shorter from proximal to distal.
In addition to the tarsals, metatarsals and phalanges, a number of
small accessory bones and sesamoid bones occur during fetal life (
Anwar et al 2005, Williams et al 1995). There are normally about ten
irregular-shaped accessory bones distributed around the tarsus; most
of these bones fuse with one of the tarsal bones prior to skeletal
maturity. There are normally about 12 sesamoid (seed-shaped) bones.
Each sesamoid bone is partially embedded in a tendon or ligament,
with the free surface of the bone forming a synovial joint with a bone
over which the tendon or ligament slides during normal function. In
addition to preventing the tendon or ligament from rubbing on the
adjacent bone, sesamoid bones tend to increase the mechanical effi-
388
Phalanges
Calcaneus
Metatarsals
Navicular Cuboid
Talus
Calcaneus
C
Phalanges
ciency (leverage) of the associated musculotendinous unit or liga-
ment. The two most important sesamoid bones of the foot, which
contribute significantly to stabilising the foot during propulsion (see
the section on the windlass mechanism later in this chapter), are the
sesamoids in the plantar aponeurosis (see later section on arches of
the foot) beneath the base of the first metatarsophalangeal joint; the
medial sesamoid is shown in Figure 15.1A.
MOVEMENTS OF THE ANKLE AND FOOT
Many of the 26 bones in each foot articulate with two or more other
bones such that there are approximately 40 joints in each foot.
Consequently, most movements of the foot involve a large number
of joints, and the movement of individual joints in each movement
is difficult to describe. However, as in most movements of the body,
there tends to be high degree of functional interdependence between
the joints of the foot, especially between the intertarsal and tarsometa-
tarsal joints, such that movement of one joint tends to bring about
fairly predictable movement in adjacent joints (Kitaoka et al 1997a,
Nester 1997, Singh et  al 1992). A group of joints with a relatively
high degree of functional interdependence is called a joint complex
(Peat 1986). The term ‘rearfoot complex’ is frequently used to describe
the functional interdependence between the ankle, subtalar and mid-
tarsal joints (Bowden & Bowker 1995, Downing et  al 1978, Nester
1997).
Ankle joint
The ankle joint is a hinge joint that facilitates rotation about an axis
of rotation which runs approximately 20° anterosuperiorly in the
sagittal plane with respect to the horizontal plane and 20° anterome-
dially in the horizontal plane with respect to the coronal plane (Fig.
15.2) (Singh et al 1992). Consequently, the movement of the ankle
joint is triplanar (i.e. movement occurs simultaneously in the sagittal,
Chapter | 15 | Structure and function of the foot
ST
23
ST
42
A Posterior talar
A articular surface
20
20
Figure 15.2  Orientation of axes of rotation of the ankle (A) and subtalar
(ST) joints.
Vertical
Anteroposterior
Mediolateral
Figure 15.3  Reference axes of the foot.
coronal and horizontal planes), with movement predominantly in the
sagittal plane. Movement in the sagittal, coronal and horizontal
planes occurs about the mediolateral, anteroposterior and vertical
axes, respectively (Fig. 15.3). Sagittal plane motion of the foot about
the ankle joint is usually referred to as plantar flexion and dorsiflex-
ion. In dorsiflexion, sometimes referred to as true flexion of the ankle,
the dorsal (superior) surface of the foot is drawn closer to the shin.
In plantar flexion, sometimes referred to as extension of the ankle, the
plantar (inferior) surface of the foot is pushed further away from the
shin (pointing the toes).
Subtalar joint
The subtalar joint is part synovial and part syndesmosis. The anterior
synovial part of the joint is separated from the posterior synovial part
of the joint by a funnel-shaped channel called the sinus tarsi. The
sinus tarsi runs more or less horizontally in an oblique posteromedial
to anterolateral direction (Fig. 15.4) with the funnel opening out later-
ally. The posterior talar articular surface of the calcaneus is convex and
articulates with the reciprocally shaped concave posterior calcanean
articular surface of the talus. The anterior talar articular surface of the
calcaneus (located on the superior aspect of the sustentaculum tali)
Head
Anterior talar Anterior calcanean
articular articular surface
surface
Sulcus tali
Sulcus calcanei – superior part
– inferior part of of sinus tarsi
sinus tarsi Posterior calcanean
articular surface
A B
Figure 15.4  Articular surfaces of the right subtalar joint. (A) Superior
aspect of the right calcaneus. (B) Inferior aspect of the right talus.
is concave and articulates with the reciprocally shaped convex anterior
calcanean articular surface of the talus. Whereas Figure 15.4 shows
only one articular surface in the anterior synovial part of the subtalar
joint, there are frequently two adjacent articular surfaces. Four distinct
variations in the number (one or two), shape and orientation of the
anterior synovial articular surfaces have been identified (Valmassy
1996). The syndesmosis part of the subtalar joint consists of a broad
interosseous talocalcanean ligament, which runs obliquely downward
and laterally from the sulcus tali (superior part of the sinus tarsi) to
the sulcus calcanei (inferior part of the sinus tarsi). The interosseous
talocalcanean ligament becomes taut in eversion (Williams et  al
1995). Distal to the anterior end of the sinus tarsi is another broad
ligament called the cervical ligament. The cervical ligament runs
obliquely upward and medially from the anterior superior aspect of
the calcaneus to the lateral aspect of the neck of the talus. The cervical
ligament becomes taut in inversion (Williams et al 1995).
Like the ankle joint, the movement of the subtalar joint is triplanar.
Inman (1976) showed that the orientation of the axis of the joint
varies considerably between individuals, with a mean orientation of
approximately 42° anterosuperiorly in the sagittal plane with respect
to the horizontal plane and 23° anteromedially in the horizontal
plane with respect to the sagittal plane (Fig. 15.2).
Pronation and supination
In contrast to the ankle and subtalar joints, there would appear to
be little empirical information on the movement of the midtarsal
joint, which is composed of a biplanar/biaxial saddle joint (calcaneo­
cuboid) and a triplanar/triaxial ball-and-socket joint (talonavicular)
(Blackwood et al 2005). However, it is clear that the rearfoot complex
facilitates triplanar movements of the foot, which are referred to as
pronation and supination (Fig. 15.5) (Kitaoka et  al 1997a, Nester
1997).
Pronation involves simultaneous abduction (vertical axis), dorsi-
flexion (mediolateral axis) and eversion (anteroposterior axis) (Fig.
15.5A,B). Similarly, supination involves simultaneous adduction,
plantar flexion and inversion (Fig. 15.5B,C). The orientation of the
rearfoot axis varies considerably, with a mean orientation of approxi-
mately 51° anterosuperiorly in the sagittal plane with respect to the
horizontal plane and 18° anteromedially in the horizontal plane with
respect to the sagittal plane (Downing et al 1978).
Using 13 cadaver specimens (mean age 65 years, range 20–89 years)
and a magnetic tracking measurement system, Kitaoka et al (1997a)
investigated the contribution of the ankle joint, subtalar joint, talona-
vicular joint and first metatarsal–navicular joint to pronation, supina-
tion, dorsiflexion and plantar flexion. The results are shown in Table
15.1. As expected, the ankle is the major contributor (47.2%) to the
389
 Neale’s Disorders of the Foot

Table 15.1  Contribution of movement between the navicular and first metatarsal (met–nav) and movement of the ankle, subtalar and
talonavicular joints to pronation, supination, dorsiflexion and plantar flexion (adapted from Kitaoka et al 1997a)

DORSIFLEXION–
PRONATION– PLANTAR PLANTAR
PRONATION SUPINATION SUPINATION DORSIFLEXION FLEXION FLEXION
Joint Degrees % Degrees % Degrees % Degrees % Degrees % Degrees %

met–nav 13.6 ± 3.9 43.3 3.3 ± 1.5 4.4 16.9 15.9 1.7 ± 1.1 6.9 11.8 ± 5.5 19.1 13.5 15.6
tal–nav 7.6 ± 3.3 24.3 39.3 ± 11.8 52.5 46.9 44.2 3.5 ± 1.8 14.3 12.7 ± 8.4 20.6 16.2 18.8
Subtalar 2.5 ± 1.7 8.0 23.3 ± 7.3 31.1 25.8 24.3 2.7 ± 1.7 11.0 6.5 ± 4.2 10.5 9.2 10.7
Ankle 7.6 ± 4.7 24.3 8.9 ± 4.6 11.9 16.5 15.5 16.6 ± 4.8 67.8 30.6 ± 7.9 49.7 47.2 54.8
ROM 31.3 100 74.8 100 106.1 100 24.5 100 61.6 100 86.1 100

ROM: range of motion

Pronation: from neutral to full pronation
Supination: from neutral to full supination
Dorsiflexion: from neutral to full dorsiflexion
Plantar flexion: from neutral to full plantar flexion
Pronation–supination: range from full pronation to full supination
Dorsiflexion–plantar flexion: range from full dorsiflexion to full plantar flexion

ARCHES OF THE FEET

A B
C the bases of the metatarsals. The shape of the arch is due to the
Figure 15.5  Supination and pronation of the foot. (A) Full pronation.
(B) Neutral position. (C) Full supination.
plantar flexion–dorsiflexion range of motion, but there are significant
contributions from the other components. The subtalar joint is often
regarded as the major contributor to the pronation–supination range
of motion, but the results of the study indicate that the contribution
of the subtalar joint (24.3%) is less than that of the talonavicular joint
(44.2%).
The movements of supination and pronation as described above
refer to movements of the rearfoot complex when the foot is not
weight bearing. When the foot is weight bearing, these movements
are constrained, depending on the magnitude and distribution of the
ground reaction force acting on the plantar part of the foot. Under
weight-bearing conditions the most noticeable movements of the foot
occur about an anteroposterior axis through the foot (similar to inver-
sion and eversion). For this reason, in describing the movement of
the foot under weight-bearing conditions the terms supination and
inversion are sometimes used synonymously, as are the terms prona-
tion and eversion. However, the actual movements of the foot under
weight-bearing conditions are modifications of supination and prona-
tion and, as such, involve simultaneous triplanar movement in all the
joints of the rearfoot complex.
The tarsals and metatarsals are arranged in the form of two longitu-
dinal arches (medial and lateral) and a single transverse arch. The
medial longitudinal arch is formed by the calcaneus, talus, navicular,
the three cuneiforms, and the first, second and third metatarsals. The
lateral longitudinal arch, which is much flatter than the medial arch,
is formed by the calcaneus, cuboid, and the fourth and fifth metatar-
sals. In combination, the longitudinal arches form a single arched
structure between the posterior inferior aspect of the calcaneus and
the heads of the metatarsals. The transverse arch runs across the foot
from medial to lateral and is formed by the anterior five tarsals and
cuboid, the lateral and middle cuneiforms, and the bases of the
middle three metatarsals, which are wedge shaped inferiorly in
coronal section.
The arched shape of the foot is maintained by ligaments (passive
support) and muscles (active support). Although the ligaments and
muscles are not very elastic, they are sufficiently so to enable the
arches to flatten slightly following contact of the foot with the ground,
such as following heel-strike in walking or running, and then recoil
(restore their normal shape) following the impact. Consequently, the
arches function like springs in order to help cushion impacts with the
ground.
Passive arch support
The ligaments on the plantar aspect of the foot are very strong and
can normally maintain the arches of the foot in upright posture in the
absence of assistance from muscles (Hicks 1961, Kitaoka et al 1997b).
The main ligaments that support the arches of the foot are:
1. The deep plantar calcaneocuboid ligament, also referred to as
the short plantar ligament, runs from the anterior tubercle
of the calcaneus to the plantar surface of the cuboid posterior
to the groove for the tendon of the peroneus longus (Fig. 15.6).
This ligament supports the calcaneocuboid part of the midtarsal
joint.

390
Chapter | 15 | Structure and function of the foot
Deltoid ligament
Interosseous ligament
Spring ligament
Long plantar Short plantar
Plantar ligament ligament
aponeurosis
Transverse metatarsophalageal ligament
Figure 15.6  Medial aspect of the right foot showing the main arch
support ligaments.
2. The superficial plantar calcaneocuboid ligament, also referred to
as the long plantar ligament, runs from the plantar surface of
the calcaneus between the posterior and anterior tubercles to the
plantar surface of the cuboid anterior to the groove for the
tendon of the peroneus longus and to the bases of the second
to fifth metatarsals (Fig. 15.6). This ligament supports the
calcaneocuboid part of the midtarsal joint and the lateral four
tarsometatarsal joints.
3. The plantar calcaneonavicular ligament, also referred to as the
spring ligament, runs from the anteroinferior aspect of the
sustentaculum tali (of the calcaneus) to the plantar surface of
the navicular (Fig. 15.6). The plantar calcaneonavicular ligament
supports the medial part of the subtalar joint (anterior synovial
part) and the talonavicular part of the midtarsal joint.
4. The deltoid ligament (medial collateral ligament of the ankle
joint) fans out from the anterior, medial and posterior aspects
of the medial malleolus to attach onto a more or less continu-
ous arc formed by the navicular, the spring ligament, the
sustentaculum tali and the talus (Fig. 15.6). The deltoid
ligament supports the medial aspects of the ankle and subtalar
joints.
5. The interosseous talocalcanean ligament is the syndesmosis part
of the subtalar joint, described earlier.
6. The plantar aponeurosis is a broad fan-shaped ligament that
spans the whole of the tarsus and metatarsus from the posterior
tubercles of the calcaneus to the bases of the proximal (first)
phalanges (Fig. 15.6). Just anterior to the tarsometatarsal joints,
the plantar aponeurosis splits into five separate bands, one to
each toe. As each band passes the plantar surface of the
corresponding metatarsophalangeal joint, it splits into a
superficial stratum (layer) and a deep stratum (Fig. 15.7). The
superficial stratum attaches to the skin of the transverse sulcus,
which separates the toes from the sole. The deep stratum divides
into two slips that attach, one medially and one laterally, onto
Sesamoid bone
A
Flexor Plantar
hallucis aponeurosis
brevis
B
Transverse Superficial Deep stratum
sulcus stratum of of the plantar
the plantar aponeurosis
aponeurosis
Figure 15.7  Sagittal sections through the first (A) and second (B)
metatarsophalangeal joints.
the proximal plantar surface of the base of the proximal phalanx
of the corresponding toe, thus forming an arch for passage of
the tendon of the flexor hallucis longus (first toe) or corre-
sponding tendon of the flexor digitorum longus (second to fifth
toes) to the distal phalanges (Williams et al 1995). The medial
and lateral slips of the plantar aponeurosis to the proximal
phalanx of the hallux merge with the tendons of the medial and
lateral parts of the flexor hallucis brevis. Each tendon contains a
sesamoid bone that forms a synovial joint with the plantar
aspect of the head of the first metatarsal. The plantar parts of
the capsules of the metatarsophalangeal joints are thickened,
and are referred to as plantar plates or plantar pads (Briggs
2005). The plantar plates are connected in series by deep
transverse intermetatarsal ligaments and by a superficial
continuous transverse metatarsophalangeal. The plantar
aponeurosis slips to each toe merge with the corresponding
plantar plate and adjoining section of the transverse metatar-
sophalangeal ligament.
Mechanically, the plantar ligaments support the arches of the feet in
two ways, as a beam and as a true arch (or truss) (Hicks 1961).
Figure 15.8A shows the type of strain experienced by a loaded beam,
i.e. compression strain on the upper surface and tension strain on
the lower surface. This is similar to the strain on the tarsals and
metatarsals imposed by the type of arch support provided by the
long plantar ligament, short plantar ligament, spring ligament, inter-
osseous talocalcanean ligament and deltoid ligament (Fig. 15.6 and
Fig. 15.8B). The strain on a true arch is different to that on a beam.
In a true arch the ends of the arch must move further apart if it is to
become flatter and the strain on the segments of a true arch is basi-
cally compression between the segments (Fig. 15.8C). This is similar
to the strain on the tarsals and metatarsals imposed by the type of
arch support provided by the plantar aponeurosis (Fig. 15.6 and
Fig. 15.8D).
391
 Neale’s Disorders of the Foot
A B
C D
Figure 15.8  Beam and arch support mechanisms. (A) Strain on a
horizontal beam when vertically loaded. (B) Strain on the bones of the
foot and beam support mechanism when the foot is vertically loaded.   the forces in the ligaments and forces in vivo. Most studies of the arch
(C) Strain on the components of a true arch when vertically loaded.   support mechanisms have been based on cadavers. For example,
(D) Strain on the bones of the foot and true arch support mechanism
when the foot is vertically loaded.
Active arch support
The passive ligamentous beam and true arch support mechanisms are
normally assisted by the muscles of the lower leg and foot. In relation
to arch support, muscles that are located entirely (have their origins
and insertions) within the foot are referred to as intrinsic muscles.
Muscles that have their origins in the lower leg and insertions in the
foot (i.e. cross the ankle joint) are referred to as extrinsic muscles.
The effect that a particular muscle has on the arches (i.e. tendency
to raise or flatten) depends on the tendency of the muscle to:
1. Plantar flex or dorsiflex the intertarsal, tarsometatarsal and
metatarsophalangeal joints. Plantar flexion of any of these joints
will tend to raise the arches and reduce the strain on the plantar
ligaments. Dorsiflexion of any of the joints will tend to flatten
the arches and increase the strain on the plantar ligaments.
2. Increase or decrease the ankle joint reaction force. In weight
bearing, the weight of the body is transmitted to the feet via
the ankle joints. Consequently, the effect of a particular
weight-bearing activity (standing, walking, running, hopping,
jumping, etc.) on the foot arches is determined by the magni-
tude of the ankle joint reaction forces; the greater the ankle joint
reaction forces, the greater the tendency to flatten the arches,
and vice versa. As demonstrated by Hicks (1961), the further
forward the line of action of body weight in relation to the
ankle joint, the greater the magnitude of the ankle joint reaction
force and, therefore, the greater the tendency to flatten the
arches.
On the basis of these criteria, Hicks (1961) classified all the intrinsic
and extrinsic muscles into four groups:
• Direct arch raiser, i.e. a tendency to plantar flex one or more of
the intertarsal, tarsometatarsal and metatarsophalangeal joints.
This group includes all the plantar intrinsic muscles and the
flexor hallucis longus, flexor digitorum longus, peroneus brevis,
peroneus longus and tibialis posterior.
• Indirect arch raiser, i.e. a tendency to shift body weight
backward (toward the ankle joint), which tends to reduce the
magnitude of the ankle joint reaction force and, therefore,
392
reduce arch flattening. This group includes the extensor hallucis
longus, extensor digitorum longus and tibialis anterior.
• Direct arch flattener, i.e. a tendency to dorsiflex one or more of
the intertarsal, tarsometatarsal and metatarsophalangeal joints.
This group includes the extensor hallucis longus, extensor
digitorum longus and tibialis anterior.
• Indirect arch flattener, i.e. a tendency to shift body weight
forward (in front of the ankle joint), which tends to increase the
magnitude of the ankle joint reaction force and, therefore,
increase arch flattening. This group includes the flexor hallucis
longus, flexor digitorum longus, peroneus brevis, peroneus
longus, tibialis posterior, gastrocnemius and soleus.
Interaction of the arch support mechanisms
Whereas it is generally accepted that the passive (beam and true arch)
and active (muscle) mechanisms both contribute significantly to arch
support (Norkin & Levangie 1992), the relative contribution of the
mechanisms in different weight-bearing activities has yet to be deter-
mined. This lack of information reflects the difficulty of measuring
Kitaoka et al (1997b) investigated the role of the plantar ligaments in
the stability of the longitudinal arches of the feet under normal
loading (upright standing posture) using 19 cadaver specimens (mean
age 71 years, range 20–89 years). It was found that sectioning all the
main plantar ligaments (long plantar ligament, short plantar liga-
ment, spring ligament, interosseous talocalcanean ligament, plantar
aponeurosis, deltoid ligament) resulted in complete collapse of the
longitudinal arch. The arch did not collapse after sectioning any single
ligament, but progressive collapse did occur when the ligaments were
sectioned consecutively. The effect of sectioning individual ligaments
on the degree of arch collapse (reflected in dorsiflexion of the inter-
tarsal and tarsometatarsal joints) varied considerably between speci-
mens, which suggested that the contribution of each ligament to arch
stability varies between individuals. This is, perhaps, not surprising
considering the variation in the size, shape and alignment of the
bones of the feet in normal healthy individuals (Åström & Arvidson
1995).
Whereas cadaver studies provide useful information on the passive
arch support mechanisms, they do not provide information about the
contribution of active support mechanisms or the relative contribu-
tion of the passive and active mechanisms. Research is clearly needed
in this area.
THE WINDLASS MECHANISM OF THE FOOT
As described earlier, the plantar aponeurosis spans the whole of the
tarsus and metatarsus by linking the inferior aspect of the calcaneus
with the plantar surfaces of the bases of the proximal phalanges of
the toes (Fig. 15.6). Consequently, extension of the metatarsophalan-
geal joints winds the plantar aponeurosis around the heads of the
metatarsals, like a cable being wound around a windlass, which simul-
taneously raises the longitudinal arch (Fig. 15.9). This action is
referred to as the windlass mechanism of the foot (Hicks 1954).
Flexion of the metatarsophalangeal joints unwinds the plantar apone-
urosis and lowers the longitudinal arch; this action is referred to as
the reverse windlass (Aquino & Payne 2000).
The reverse windlass action is a feature of the loading phase (from
heel-strike to foot-flat) and much of the single-support phase in gait.
During this period, the rearfoot complex normally pronates, which
unwinds the plantar aponeurosis and lowers the longitudinal arch.
Chapter | 15 | Structure and function of the foot
A B
Figure 15.9  The windlass effect of the plantar aponeurosis resulting
from dorsiflexion of the metatarsophalangeal joints.
This movement is associated with extension of the midtarsal joint,
which is sometimes referred to as ‘unlocking’ the midtarsal joint
(Blackwood et al 2005, Sobel et al 1999). In the foot-flat position the
tension in the plantar aponeurosis exerts a flexor moment on the
proximal phalanges (pushes the pads of the toes against the ground),
which extends the length of the base of support and, consequently,
reduces the pressure on the plantar surfaces of the heads of the meta-
tarsals. In addition, the tension in the plantar aponeurosis, in associa-
tion with tension in the intrinsic muscles, prevents excessive flattening
of the longitudinal and transverse arches and provides a stable base
of support.
The windlass action is a feature of the push-off in gait (from heel-off
to just before toe-off). During this period, the rearfoot complex nor-
mally supinates in association with extension of the metatarsophalan-
geal joints (Fig. 15.9B). These actions raise the longitudinal arch,
which stabilises the foot and provides a firm base of support for the
push-off. The windlass movement is associated with flexion of the
midtarsal joint, which is sometimes referred to as ‘locking’ the mid-
tarsal joint (Blackwood et al 2005, Sobel et al 1999).
The windlass action during push-off in gait is most effective (rapid
initiation and completion of arch raise) when the leverage of the
plantar aponeurosis is maximum. This occurs when (i) the sesamoids
are located in their normal position beneath the head of the first
metatarsal (Fig. 15.7A) and (ii) the long axes of the first metatarsal
and phalanges of the hallux are more or less in line (Fig. 15.10A). Not
surprisingly, this would appear to be the normal orientation of the
sesamoid bones and first metatarsophalangeal joint, as significant
non-alignment of the first metatarsal and proximal phalanx seems to
be rare in children (Kilmartin 1991).
With increase in age, many people develop hallux valgus, also
referred to as hallux abducto valgus (Thomas & Barrington 2003).
Hallux valgus is a complex progressive condition that is characterised
by lateral deviation (valgus abduction) of the hallux and medial
deviation of the first metatarsophalangeal joint (Fig. 15.10B). Unless
treated, hallux valgus results in a progressive increase in the hallux
abductus angle (i.e. the angle between the long axes of the first meta-
tarsal and proximal phalanx) (Fig. 15.10B). When the hallux abductus
angle is less than 15°, the condition tends to be asymptomatic.
However, increases in the hallux abductus angle above 15° tend to
be associated with increasing pain and discomfort around the first
metatarsophalangeal joint (Easley & Trnka 2007, Menz & Lord 2005).
Relative to the first metatarsophalangeal joint, any increase in the
hallux abductus angle will tend to displace laterally the lines of action
of the plantar aponeurosis and tendons of the intrinsic and extrinsic
muscles that cross over the first metatarsophalangeal joint from the
metatarsal to the hallux. Consequently, the sesamoid bones will also
be displaced laterally relative to the first metatarsophalangeal joint,
resulting in subluxation of the joints between the sesamoid bones and
A B
Figure 15.10  (A) Superior aspect of the right foot with a hallux
abductus angle of approximately 5°. (B) Superior aspect of the right foot
with a hallux abductus angle of approximately 35°.
the head of the first metatarsal (Fig. 15.10B). Subluxation of these
joints will decrease the leverage of the windlass about the first meta-
tarsophalangeal joint and, consequently, tend to result in increased
force in the muscles supporting the arches during push-off in order
to compensate for the loss in leverage of the windlass. The increased
muscle force will tend to increase the hallux abductus angle and,
consequently, increase (i) the pressure on the articular surfaces
between the medial sesamoid and the head of the first metatarsal, (ii)
the strain on the intertransverse ligament and metatarsophalangeal
ligament between the first and second metatarsophalangeal joints,
and (iii) the pressure exerted by the shoe on the medial aspect of the
first metatarsophalangeal joint (Tanaka et  al 1997). This pattern of
loading, if prolonged, is likely to result in discomfort, pain, inefficient
gait, impaired balance and an increased risk of falling, especially in
the elderly (Menz & Lord 2005).
STRUCTURAL ADAPTATION OF THE
MUSCULOSKELETAL SYSTEM
In any body position other than the relaxed recumbent position, the
musculoskeletal system is likely to be subjected to considerable
loading. In response to the forces exerted on them, the musculoskel-
etal components experience strain (i.e. they are deformed to a certain
extent), and the greater the force, the greater the strain. Under normal
circumstances the musculoskeletal components adapt their external
form (size and shape) and internal architecture (structure) to the
time-averaged forces exerted on them in order to more readily with-
stand the strain (Carter et  al 1991). However, when the degree of
strain experienced by a particular component exceeds its strength, it
becomes injured. Consequently, there is an intimate relationship
393
 Neale’s Disorders of the Foot

between the structure and function of the musculoskeletal system

(Watkins 1999). A C E

Structural adaptation in bone

The last 30 years have produced much of the present knowledge con-
cerning the adaptation of musculoskeletal components to changes in
time-averaged load (Frost 1988a,b, 1990). However, the fundamental
concepts concerning the adaptation of bone were established over
100 years ago (Gross & Bain 1993). In 1892, Julius Wolff (1836–
1902) summarised the contemporary views of bone adaptation to
changes in time-averaged load in what came to be known as Wolff’s
law (Wolff 1988). Wolff’s law, which has been shown to be more or
less correct, hypothesised that bone adapts its external form and inter-
nal architecture to the time-averaged load exerted on it in an ordered
and predictable manner to provide optimal strength with minimal
bone mass.
The adaptation of bone to time-averaged load is referred to as
‘modelling’. In normal growth and development, modelling has
been estimated to account for 20–50% of the dimensions of mature
bones (Frost 1988b). Some of the load experienced by bone is due
to the weight of body segments. However, this source of loading is
small relative to the loads exerted by muscles (Schoenau & Frost
2002, Watkins 1999). From birth to maturity, bone has the capacity
to model external form and internal architecture. However, the
capacity to model external form gradually decreases and virtually
ceases at maturity. The capacity to model internal architecture also
decreases with age, but is retained to some extent throughout life. In
general, bone adapts to changes in time-averaged loads by increasing
or decreasing bone mass to maintain an optimum strain environ-
ment. In bone, the optimum strain environment is characterised by
minimal flexure (or bending) strain and an even distribution of
stress (usually compression stress) across articular areas. An even dis-
tribution of stress across articular areas is maintained by modelling
in accordance with the phenomenon of chondral modelling
(Frost 1973).
The chondral modelling phenomenon
All bones that develop from hyaline cartilage via endochondral ossi-
fication experience chondral modelling, i.e. the rate and amount of
new bone formed by hyaline cartilage depends on the amount and
form of load exerted on it. Chondral modelling applies to articular
cartilage, epiphyseal plates, insertions of tendons and ligaments, apo-
physeal plates, end plates in symphysis joints, and sesamoid bones
(Frost 1979).
In a long bone the size and shape of the epiphyses and metaphyses,
and consequently the orientation of the epiphyses of a bone to its
shaft, are determined by chondral modelling in articular cartilage and
epiphyseal plates. When a synovial joint is maximally congruent, the
loading on articular cartilage and epiphyseal plates tends to be evenly
distributed. Incongruence results in an unequal distribution of load
across articular cartilage and epiphyseal plates. If prolonged, such
unequal loading results in modelling to restore maximal congruence.
However, the actual changes that occur depend on the extent of the
changes in the patterns of loading on the articular cartilage and epi-
physeal plates. If the changes in loading remain within the normal
range, then a negative-feedback mode of modelling is invoked, result-
ing in restoration of normal congruence with normal or slightly
abnormal alignment of the bones. However, if the changes in loading
are outside the normal range, then a positive-feedback mode of mod-
elling is invoked, which aggravates the condition, resulting in progres-
sively worsening malalignment.
B D F
Figure 15.11  Modelling of metaphyses and epiphyses: effect of
negative-feedback mode in relation to an abductor–adductor imbalance
at the knee.
Modelling of metaphyses and epiphyses
A functionally normal joint is a congruent joint that transmits loads
across the articulating surfaces in a normal manner. An anatomical
malalignment at the knee, or any other joint, will be functionally
normal if the malalignment stabilises (does not get progressively
worse). In these cases, the anatomical malalignments represent
normal modelling in response to abnormal patterns of loading.
The skeletal adaptations ensure normal transmission of loads across
the joints. Figure 15.11 illustrates the effect of negative feedback
in relation to abductor–adductor muscle imbalance at the knee.
Figure 15.11A represents a knee with normal balance between the
abductor and adductor muscles (i.e. the resultant horizontal force
at the knee is zero). This situation is associated with normal align-
ment between the femur and tibia and an even distribution of load
across the articular surfaces and epiphyseal plates (Fig. 15.11B).
Figure 15.11C shows the same knee with an abductor–adductor
imbalance such that there is a net medially directed horizontal
force at the knee tending to increase the degree of genu valgum.
Figure 15.11D shows the unequal pattern of loading on the articu-
lar surfaces and epiphyseal plates associated with the muscle imbal-
ance. Assuming that the unequal loading is within the normal
range, the negative-feedback mode is invoked. The rate of growth
of the lateral aspects of the epiphyses and metaphyses is increased
and the rate of growth of the medial aspects of the epiphyses and
metaphyses is decreased such that normal congruence is restored
(with net zero horizontal force at the knee) at the expense of an
abnormal alignment between the femur and tibia (i.e. much
reduced genu valgum or even slight genu varum relative to most
individuals) (Fig. 15.11E,F).
Whether or not a particular joint is anatomically malaligned during
childhood, the only time when it may become painful (excluding
injuries and pathological conditions not due to loading) is during
adulthood, when the bones are no longer capable of modelling in
response to abnormal loading. In most adults, abnormal patterns of
loading are the result of an increasingly sedentary lifestyle in which
body weight gradually increases and muscle strength gradually
decreases.
Modelling of articular surfaces
Minor incongruences between articular surfaces in synovial joints
tend to result in large changes in the compression stress experienced
by different parts of the articular surfaces (Calhoun et al 1994). This
is especially the case in joints with pulley-shaped articular surfaces
such as the ankle joint (Fig. 15.12). Under normal circumstances, the
subtalar joint contributes to inversion and eversion of the foot (Fig.

394
Chapter | 15 | Structure and function of the foot

A B C D 15.12A,B). However, if movement at the joint is absent or limited,

inversion and eversion of the foot twists the talus in the tibiofibular
mortise, resulting in excessive compression stress on those parts of the
articular surfaces that remain in contact (Fig. 15.12C). The excessive
loading on the impinging areas reduces or halts growth in these areas,
while growth of the unloaded areas proceeds at the normal rate.
Consequently, the shapes of the articular surfaces adapt to the abnor-
mal loading conditions by forming a rounded surface in the coronal
plane rather than a pulley-shaped surface, and the ankle joint as a
whole resembles a ball and socket joint rather than a hinge joint (Fig.
15.12D) (Frost 1979).
Figure 15.12  Modelling of articular surfaces.

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