6 Br J Sports Med 1999;33:6–13 Br J Sports Med: first published as 10.1136/bjsm.33.1.6 on 1 February 1999. Downloaded from Review The foot in sport K P Sherman Introduction shape is produced partly by the “windlass Foot disorders in sport can present very eVect”; the plantar aponeurosis inserts into the diYcult diagnostic and treatment problems. base of the proximal toe phalanges and when Many treatments have not been subjected to the toes are dorsiflexed the plantar fascia is properly conducted randomised controlled tightened and the medial longitudinal arch trials. Success in treating these disorders relies increases in height. The axis of the subtalar on a knowledge of the anatomy and kinesiology joint lies about 41° to the horizontal in the sag- of the foot and an understanding of the ittal plane and 23° to the midline axis of the interrelationship both between the diVerent foot in the transverse plane1; as a result of this parts of the foot and between the foot and more oblique axis, torque around the longitudinal proximal parts of the anatomy. Prevention and axis of the lower leg is converted into torque treatment require a knowledge of individual around the longitudinal axis of the foot (the sports, and long term success requires a team “torque translator eVect”). During normal gait approach which may involve coach, physio- the tibia internally rotates at initial foot loading therapist, doctor, orthotist, parent (in the case and the foot pronates (see below) to allow flex- of children), and many other key personnel, but ibility and adaptation to the ground. At the which, above all, must include the sportsperson start of “toe-oV” the tibia externally rotates and him/herself. the foot supinates to form a more rigid “lever”. In preparing this paper a search was made In addition to passive changes in shape, the using Medline and the Cochrane database for longitudinal arches of the foot are influenced the past 10 years, and a manual search of by muscle activity during propulsion, particu- relevant journals was carried out. larly the posterior and anterior tibialis and per- oneus longus muscles. The intrinsic muscles attach proximally to the tarsal joints and during Orthopaedic Anatomy and kinesiology Department, Castle The foot can be considered to have two propulsion have an additional stabilising eVect http://bjsm.bmj.com/ Hill Hospital, Castle primary functions: stance and propulsion. on the arches. Road, Cottingham, During these functions it must be able to adapt Examination of the foot must take these dif- East Yorkshire to varying loads and surfaces, and its structure fering functions and postures into account. HU16 5JQ, United Kingdom reflects this. During stance the foot is a “mobile K P Sherman adaptor”. The medial and longitudinal arches Terminology are supported passively by the ligaments and There is unfortunately a great deal of confusion Correspondence to: plantar fascia (during quiet standing the in the terminology of foot movement and pos- Mr K P Sherman. on September 27, 2021 by guest. Protected copyright. muscles do not contribute significantly). Dur- ture. It is important to distinguish between a Accepted for publication ing propulsion the foot changes shape and description of a movement of a specific joint 9 September 1998 becomes a more “rigid lever”. This change in and the movement of the entire foot/ankle complex. INVERSION AND EVERSION These terms refer to tilting of the sole of the plantar aspect of the foot towards, or away from, the midline of the body respectively. The presence of a fixed inversion is often referred to as varus, and the presence of a fixed eversion is referred to as valgus. When applied to an indi- vidual joint varus and valgus also refer to angu- lation towards or away from the midline of the body respectively. ADDUCTION AND ABDUCTION Adduction and abduction refer to angulation towards or away from the midline, and in the mid- and fore-foot this movement is in a plane parallel to the plantar surface of the foot. In the case of the digits, the reference line is the mid- Figure 1 Photograph showing (A) pronated forefoot and (B) supinated forefoot. line of the second toe. The foot in sport 7 Br J Sports Med: first published as 10.1136/bjsm.33.1.6 on 1 February 1999. Downloaded from PRONATION AND SUPINATION (f) observation during performance of sport These terms cause some of the greatest confu- (either directly or by video-recording) sion. Gray’s anatomy uses the analogy of a (g) entire lower limb “twisted plate”2 when applied to the forefoot. If the heel is abducted on a level surface the mid- (h) footwear and fore-foot “untwist” (supinate) and the With the patient standing, the shape and over- medial longitudinal arch is lowered. A similar all alignment of the foot can be assessed and untwisting or supination occurs if the heel is the longitudinal arch observed. The patient perpendicular to the ground and the forefoot is placed on a wedge based medially (fig 1). If the should then stand on tiptoe (the heel raise test). heel is adducted, the forefoot is pronated to This test should be performed with both feet maintain a level forefoot and the medial longi- together (to assess and compare heel alignment tudinal arch is raised. Pronation and supination and longitudinal arches) and one foot at a time of the forefoot in this manner occurs around (the single heel raise test) to assess the Achilles the axis of the least mobile second metatarsal. tendon and tibialis posterior function. During Pronation allows a downward rotation of the the single heel raise test the knee must be kept medial border of the foot and hallux towards extended to prevent the heel being lifted by the ground. Supination brings the lateral rolling forward on the foot. border into more direct plantigrade contact. The examination performed with the patient Clinically Alexander3 has described supina- sitting must be methodical and anatomically tion of the foot/ankle complex as a combination based. The foot should be examined for of adduction of the foot, inversion of the subta- callosities or other evidence of skin or nail lar joint, and plantar flexion, and pronation as pathology. The positioning of callosities is an the converse (abduction, eversion, and dorsi- important clue to excessive loading of particu- flexion respectively). The terms pronation and lar parts of the foot. The individual structures supination are applied when the foot is should be palpated to identify any swelling and load-bearing. the precise position of any tenderness. Exam- ination of the joints of the forefoot and toes should be carried out with the ankle in neutral, Pronation is not synonymous with pes dorsiflexed, and plantarflexed positions. planus When the foot is examined with the patient prone, the forefoot should be adjusted in posi- tion until the medial border of the talar head History taking aligns with the navicular tuberosity; in this The history must include reference to a position the calcaneus is in neutral position in number of key features: the frontal plane.3 The forefoot frontal plane (a) acute or chronic onset of symptoms alignment can then be assessed relative to the (b) change of training (including any change calcaneus. in playing surface4) Owing to the interrelationship between foot http://bjsm.bmj.com/ shape and torsional and angular deformities in (c) change of footwear the tibia, knee, femur, and hip, the entire lower (d) “start up pain” first thing in the morning limb must be examined. Torsional and angular or after sitting deformities that might normally be considered (e) pain associated with particular exercises “within the normal range” may be of signifi- or activities cance to the regular or high level sport partici- (f) progressively increasing pain pant, particularly if combined with other (g) rest pain “mild” problems in the foot itself. on September 27, 2021 by guest. Protected copyright. (h) stiVness (i) observable swelling Box 1: Interrelationship between the (j) weakness or instability joints and bones of the lower limb (k) callus formation + Valgus and varus of the knee will aVect (l) any observed change of shape in the foot, abduction/adduction of the heel when or altered foot posture. standing, and this will aVect pronation/ supination of the fore-/mid-foot Examination of the foot + Owing to the torque translator eVect of Examination of the foot must include evalua- the subtalar joint, external rotation of the tion of both static and dynamic functions and lower leg, with the foot on the ground, must be accompanied by an examination of the will be associated with a raised medial entire lower limb. Fixed deformities must be longitudinal arch (pronated forefoot); distinguished from flexible or passively correct- conversely internal rotation will lower the able ones. The examination should include: medial longitudinal arch (a) standing (visualised from the front and from behind) Finally attention should always be given to the footwear. Not only may inspection of the (b) standing with heel raised footwear give important clues to abnormal gait, (c) walking or loading patterns, the footwear itself may be (d) sitting Figure 2 Severely worn the source of the problem (fig 2). Inappropriate sports shoes. (e) prone with foot over end of couch footwear for the particular sport, or for a 8 Sherman particular foot, may contribute to, or cause, common in the non-athletic and is often Br J Sports Med: first published as 10.1136/bjsm.33.1.6 on 1 February 1999. Downloaded from problems in the foot (and elsewhere in the associated with hindfoot structural abnor- lower limb).5–7 The “ideal” running shoe is malities.