Forefoot varus is a position of the forefoot that is inverted when the subtalar joint is in its defined neutral position and the midtarsal joint is maximally pronated. To get this foot flat on the ground the rearfoot has to pronate. This can lead to a number of problems.
Forefoot supinatus is also an inverted position of the forefoot when the subtalar joint is in its neutral position and the midtarsal joint is maximally pronated. However, it is a very different beast to forefoot varus. Forefoot varus is an osseous deformity, but forefoot supinatus is a soft tissue contracture. When the rearfoot pronates, for whatever reason, the forefoot can not go through the ground, so it is in a relatively inverted position compared to the rearfoot position. As the soft tissues adapt to this position, a forefoot supinatus develops.
So, forefoot varus is the cause of excessive foot pronation and forefoot supinatus is the result of rearefoot pronation. Forefoot varus is not very common and forefoot supinatus is very common. The management of them is very different and potentially can cause problems if it is done wrong.
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Golf is a popular sport or activity for participation and for competition. It attracts millions of dollars in sponsorship and prize money (and a few controversies!). There are a lot of golf forums on the web for discussion of golfing and related issues. Foot orthotics for golf do raise some issues when they are indicated. On the one hand you need a fairly supportive foot orthotic to control the foot over the long distances that get walking during a game of golf (and unless you are a pro, you have to carry or pull the extra weight of the golf clubs). On the other hand, the rearfoot area of an orthotic for a golfer needs to be reasonably flexible to allow for the side to side motion that happen in stance during a golf swing. Just what needs to be done to help the golf biomechanics is always going to be one of compromises between these two competing considerations.
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The Cluffy Wedge is an extension for a foot orthotic that has been getting some attention lately. All it is aimed at doing is slightly dorsiflexing the hallux, which many call preloading the hallux. The effect of this is to bring the windlass mechanism into effect earlier, which is really helpful for those with a delay in windlass action (they require more dorsiflexion before the resistance of the windlass is felt). It is also use for functional hallux limitus. The Cluffy Wedge was developed by Dr James Clough who published a paper on it in JAPMA and has lectured on it. There are a number of You Tube Videos on the Cluffy Wedge.
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There are many ways to measure or determine the posture or alignment of the foot. The problem with any one method is that the foot may be normal or abnormal on that measure (eg arch height) and yet be the oposite in another measure (eg heel alignment). So the foot may be classified as being normal or abnormal depending on the measure used. Tony Redmond developed the Foot Posture Index to overcome this problem. The foot posture index is a composite measure of 6 factors that get added together to give an index of foot posture or alignment. The Foot Posture Index has been shown in most studies to be reliable and also having some validity.
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The traditional test of ankle joint range of motion requires that the subtalar joint should be kept in its neutral position. This is because of the range of dorsiflexion that can occur at that joint and by allowing that to happen, you can get a false impression of ankle joint dorsiflexion. The lunge test is a weightbearing test of ankle joint range of motion. It was largely dismissed by many when it was initially described as it did not keep the subtalar joint in it neutral position. However, over time more and more people found the lunge test helpful and some studies found it to be predictive of injury. So maybe keeping the subtalar joint in its neutral position is not that important when assessing ankle joint range of motion.
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You certainly see these claims made often. Someone with an anti foot orthotic agenda will say “Do not use foot orthotics as they will weaken the arch muscles“. Those with an anti-running shoe agenda will say something like “Running shoes will weaken the muscles which is why you should run barefoot.” Given the strength that these assertions are made with, you would expect there was some good evidence backing them up. Well, there is no evidence that foot orthotic or running shoes weaken the muscles.
There was this commentarty on running shoes: Do running shoes weaken muscles? and this commentary on foot orthotics: Do foot orthotics weaken the arch muscles?
From what I can understand is that running shoes do not weaken the msucles and foot orthotic do not either – they may even increase it!
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The windlass mechanism is a mechanism in the foot first described by Hicks in 1954. In yachting, the windlass is that lever system that is used to pull in sails. In a wishing well, it is the pulley system that is used to raise and lower the bucket. In the foot, the hallux is the lever that pulls the plantar fascia or aponeurosis around the head of the first metatarsal. The effects of the windlass mechanism, which occurs when the heel comes off the ground are to elevate the arch of the foot and supinate the foot. This has to co-ordinate with many other functions, such as external rotation of the leg during late in the stance phase. Any dysfunction of the windlass mechanism interferes with this process and can cause problems. Foot orthotics needed to incorporate design parameters that enhance the function of the reverse windlass mechanism.
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The two main risk factors for medial knee osteoarthritis is obesity and a higher external knee adduction moment. Laterally wedging the foot or shoe has been shown to reduce this adduction moment in many people (but not all) and clinical trials appear to show that it is helpful in many people (but not all). Some review have recently concluded that they may not be beneficial. However, the response to lateral wedges is very subject specific, in that it is hypothesised that those with a more rigid foot may be more responsive to lateral wedging of the foot.
Also of interest is that no research has yet shown any increase in foot problems with the use of lateral wedges. For the latest on the research see: Lateral Wedging for Medial Knee Osteoarthritis.
A highly amusing post on Podiatry Arena by Robert Issacs on how to succeed in podiatric biomechanics probably sums up the state of the play in the area. He may not have intended this to be a summary and intended it to be more amusing. There are so many clinical biomechanical theories that are used in podiatry to explain how foot orthotics work and how to use foot orthotics in clinical practice. The problem with some often alleged newer is that there is a product or $ attached to them. This is why the post is so funny. It is a shame that the people who its most aimed at, probably will not read it or probably will not now it was them that is being talked about. Talk about lost mojo.
SALRE or subtalar joint rotational equilibrium is a model of how foot orthotics work at changing the joint moments about the subtalar joint axis. It was initially proposed by Dr Kevin Kirby DPM and is finding increasing support and as a model it is consistent with the research and clinical experience. The theoretical rationale behind the model is sound and plausible. It is not without it critics: Challenging SALRE
