Journal of the American Podiatric Medical Association Vol 99 No 4 July/August 2009 317

Podiatric physicians have been using in-shoe appli-

ances and varied theories and therapies to treat gait-
related symptoms since the profession began to de-
velop in the 18th century.
1
More recently, three main
theories have become established in the podiatric lit-
erature in relation to treating foot-related lower-quad-
rant symptoms. The subtalar joint neutral (STJN) the-
ory, tissue stress (TS) theory, and sagittal plane
facilitation (SPF) theory make up the most accepted
approaches to the foot in relation to gait dysfunc-
tion.
2, 3
Although these theories appear to be diverse
in their application, the common consensus of out-
comes for treatment of lower-limb symptoms from
any of these paradigms is generally positive.
4-18
We
present theoretical standpoints and methods of or-
thotic prescription; critical review of these theories
is available elsewhere.
2, 3
Foot Morphology Theory
Between 1958 and 1959, Merton L. Root, DPM,
19
pio-
neered functional foot orthoses, conducted hundreds
of biomechanical assessments, and began to define
the STJN position. The theory that he and his col-
leagues created is based on the premise that a foot is
functioning normally when STJN position occurs im-
mediately after heel strike and at the end of the mid-
stance phase of gait.
20
Foot morphology (FM) was
characterized and referenced to this STJN position,
21
and the relationship between this and normal or ab-
normal foot function was established.
20
Although Dr.
Root may have been developing orthoses as part of
his clinical practice,
19
no further descriptive text on
foot orthotic prescription or manufacture was ever
made available. However, many authors have cited
Dr. Root in their interpretation of their own texts and
literature on foot orthoses, often using terminology
such as Rootian or Modified Rootian foot orthoses.
22-30
It may be unwise to assume that Dr. Root would
agree with the interpretation of his work, although
all of these contributors base their description of or-
Background: Diverse theories of orthoses application have evolved with the continual de-
velopment of podiatric biomechanics and orthotic management. This theoretical disparity
can lead to confusion in clinical, educational, and research situations. However, although
approaches are varied, the common consensus is that foot orthoses outcomes are gener-
ally positive.
Methods: Three main podiatric theories exist: the foot morphology theory, the sagittal
plane facilitation theory, and tissue stress theory. By researching the available literature,
the perspectives of all three theories are summarized, emphasizing areas of conflict and
agreement.
Results: Through a unified theory, we introduce a premise by which the similar orthotic
outcomes obtained from the three main podiatric theories may be explained.
Conclusions: It remains up to the individual podiatric physician to decide which method
to use to prescribe a foot orthosis. It may be of benefit to encompass all approaches
rather than be dogmatic or exclusive. (J Am Podiatr Med Assoc 99(4): 317-325, 2009)
*The Podiatry and Chiropody Centre, Portsmouth, Hants,
United Kingdom.
Gloucestershire Podiatry Department, St. Pauls Med-
ical Centre, Cheltenham, United Kingdom.
Corresponding author: Paul Harradine, MSc, The Podia-
try and Chiropody Centre, 77 Chatsworth Ave, Portsmouth,
Hants, PO6 2UH United Kingdom. (E-mail: podiathing@yahoo
.co.uk)
A Review of the Theoretical Unified Approach to Podiatric
Biomechanics in Relation to Foot Orthoses Therapy
Paul Harradine, MSc*
Lawrence Bevan, BSc
ORIGINAL ARTICLES
318 July/August 2009 Vol 99 No 4 Journal of the American Podiatric Medical Association
thotic therapy on FM and the STJN position in some
element. The premise of this model of management
seeks to identify FM that is abnormal, eg, forefoot
varus, and prescribe an orthotic device to prevent
subsequent abnormal joint compensatory motion eg,
excessive subtalar joint (STJ) pronation.
19, 20, 24-26, 30
It
may be fair to assume that this method of podiatric as-
sessment and treatment is the most popular biomechan-
ical approach to foot function and orthoses used world-
wide by both podiatrists and other professions.
31-33
The majority of texts that describe orthoses in re-
lation to Roots work agree with the following pre-
scriptive methodology, which is generally taken from
the most comprehensive available literature on FM
theory orthoses.
22
The FM theory orthosis is designed
to balance a foot deformity with posting applied to a
rigid bespoke shell. Prescription protocol begins with
a cast of the foot in a nonweightbearing neutral posi-
tion.
34
The shape of the neutral cast is of prime impor-
tance, because it is essential to capture the correct
forefoot-to-rearfoot alignment and calcaneal inclina-
tion angle. The cast is then angled with an intrinsic
forefoot post to place the bisection of the heel at the
required position. The degree of posting to achieve
this required position is calculated by taking the value
of a patients neutral calcaneal stance position (NCSP)
and subtracting a set number of degrees in order to
allow normal pronation. The height of the STJ axis is
used to determine the amount of pronation to be al-
lowed. The rearfoot post is ground so that it is angled
an additional 4 varus for an average STJ axis. A high
STJ axis rearfoot post allows 2 of motion, and the
low STJ axis post allows 6,
35
which will control the
movement of the foot from NCSP to the prescribed
pronated position. To maintain the posting and shape
of the orthosis, only rigid materials are recommend-
ed, such as acrylic or carbon fiber plus an acrylic
rearfoot post. The shell is classically cut to 25% of the
width of the first ray.
Sagittal Plane Facilitation Theory
Howard Dananberg, DPM, first published his theories
of SPF in 1986.
36
He and his colleagues have since de-
veloped a theory that highlights the importance of the
foot as a pivot that rocks forward from heel to toe,
thereby allowing adequate hip extension leading up
to the propulsive phase of gait. He proposes that this
hip extension allows a normal stride and therefore an
efficient and erect gait.
5, 36-39
Functional hallux limitus
and ankle equinus are two examples of pathology
that can restrict foot movement and result in what
Dananberg
40
terms a sagittal plane blockade. Ankle
equinus is stated to be the inability to dorsiflex to
100, and functional hallux limitus is defined as a first
metatarsophalangeal joint (MTPJ) that structurally
has a normal range of motion but is unable to dorsi-
flex adequately at the appropriate time in gait. Danan-
berg has mostly related SPF theory to more proximal
posture-related problems, such as low-back pain,
5, 39, 40
although it is possible to use this theory to explain
foot pains and abnormalities. Sagittal plane facilita-
tion theory is now well published, and like the FM
theory, is apparently being well accepted by other
professions.
39
Orthotic prescription is based upon the premise of
informed trial and error using video gait analysis and
in-shoe pressure system measures. Therefore, the
means of determining what posting, shell thickness,
heel raise, and so forth is determined without refer-
ence to the forefoot-to-rearfoot relationship or axis
height as in the FM model. Dananberg
5, 41
also cites
the use of shell modifications, such as cut-outs be-
neath the first ray and specific forefoot extensions to
encourage medial propulsion. In fact, the amount of
posting is relatively very small, eg, 1,
41
and potential-
ly totally different from what may seem necessary
from a standard static examination.
Although a specific SPF theory outcome study is
available,
5
the actual prescription method remains
sparsely documented. Dananberg has not yet pro-
duced a step-by-step guideline of his methodology,
making it difficult for practitioners to replicate this
often technologically intricate approach. Experience
guides the choice of shell modifications.
41
Dananberg
has always stated orthoses should be fabricated on
functional rather than static examination. However,
there is one reference available in which there ap-
pears to be an attempt to link SPF theory prescription
methodology with deformities identified by Root et
al.
42
Sample prescriptions are provided based on
three vaguely defined foot types. This appears to be
the closest we get to a simple prescription guideline.
Table 1 shows a summary of treatment options from
the SPF theory perspective compiled from Dananbergs
various publications and lectures.
5, 41-43
Tissue Stress Theory
Kevin Kirby, DPM,
44
first published work on varia-
tions in the STJ axis in 1987. This model is based on
assessment of the moments across the STJ and meth-
ods of changing these to decrease stress upon anatom-
ical structures.
44-46
Injured structures are identified
and pathology is mechanically related to foot func-
tion. Fuller
47
recently applied the concept of the wind-
lass mechanism and center of pressure
48
to Kirbys
earlier work. This approach employs the application
Journal of the American Podiatric Medical Association Vol 99 No 4 July/August 2009 319
of physical laws such as moments, levers, stress, and
strain curves. Tissue stress theory is based more on
the concept of kinetics as opposed to kinematics of
gait. The central concept is that pronation or supina-
tion does not cause harm but stopping the pronation
or supination does. If the center of pressure is medial
to the STJ axis during gait, a supinatory moment will
be applied to the STJ. The opposite will also occur. If
the center of pressure is lateral to the STJ axis, a
pronatory moment will be applied to the STJ. For ro-
tational equilibrium to occur, structures opposing
these moments must apply a moment of the same
magnitude. For example, the plantar fascia and the
tibialis posterior would oppose a pronatory moment
across the STJ axis. A medial or lateral shift in the
STJ axis will result in a disturbance of this equilibri-
um, and undesirable motion will occur unless a struc-
ture can increase the opposing moment. The strain
that this imposes on opposing structures, such as the
tibialis posterior, may exceed its loading capacity and
result in injury.
44-48
Symptom reduction appears to dictate treatment
outcome rather than the success or otherwise of plac-
ing the foot in an ideal position.
49, 50
Foot-related mus-
culoskeletal injury is treated with orthoses to reduce
the abnormal forces on injured structures by applying
appropriate moments to the STJ.
48, 50
Kirby
46
has con-
tested the criteria for normality set out by Root et
al,
20, 21
proposing it to be irrelevant to achieving nor-
mal foot function with an orthosis. Kirby furthers this
by commenting that a foot resting very near to STJN
in relaxed bipedal stance actually exhibits excessive
supination moments in gait. A moderately pronated
foot in stance is considered more of a normal posi-
tion.
46
Orthotic prescription choices are forefoot posting,
rearfoot posting, and forefoot extensions in a valgus
or varus orientation. Negative casts are often modi-
fied at the time of impression, depending on the re-
quired shell shape, to apply the correct moments to
the foot, eg, the first ray is dorsiflexed or plantarflexed
to alter forefoot to rearfoot alignment.
49
Large degrees
of forefoot posting can be used, up to 5 to 10.
46, 50
The magnitude of pathologic moments dictates the
amount of posting required rather than modifying a
cast or orthotic shell based on the STJN position. The
general width of the orthoses is not specified, although
they appear commonly wider than FM theory prescrip-
tions.
50
In contrast to the FM theory, a change in mag-
nitude of forces, not in joint position, is required to
reduce symptoms. Greater orthotic reaction force is
required if the ground reaction force is producing ab-
normal moments. To supply this increased orthotic
reaction force, Kirby designed and published a shell
modification called the heel skive.
51
By modifying the
positive cast, the heel skive can be applied, as re-
quired, to the medial or lateral aspect of the STJ axis.
As with the SPF theory, there is no actual prescrip-
tion protocol available for the production of orthoses
based on the TS theory, although more literature is
available.
50, 52
A Unified Theory
It is reasonable to assume that no clinician would con-
tinue to use a theory that was not working to relieve
their patients symptoms. Rationally there must be
beneficial aspects of treatment from FM, SPF, and TS
theory perspectives. Although the three main podi-
atric biomechanics paradigms conflict in principle
(Table 2), all demonstrate an agreement that the foot
essentially has three main areas of function
20, 40, 46, 50
:
1) to be stable and maintain a congruent structure
Table 1. Summary of Treatment Options from the SPF
Perspective
5, 41-43
Orthoses are custom made from foot impressions, but the
method of casting is not highlighted. Dananberg has
recently been part of a venture to produce a noncustom
prefabricated appliance, the Vasyli Howard Dananberg
(VHD) orthotic (Vasyli Medical, Queensland, Australia),
which may eliminate the need for casting.
Use static and dynamic assessment to establish any need
for correcting a leg length difference with heel raises.
Manipulate areas of reduced motion such as the first
metatarsophalangeal joint and talocrural joint, if required.
Supply firm heel raises to reduce the effects of an ankle
equinus.
Use first-ray shell excisions if there is functional hallux limi-
tus. The size of the cut-out is dependent on dynamic find-
ings. Use a kinetic wedge and digital platform if
necessary.
Dananberg believes a rearfoot post can be potentially harm-
ful due to encouraging lateral avoidance and advocates
the use of flat rearfoot posts. Rearfoot posting is recom-
mended in situations such as a medial heel strike; the
maximum required is considered to be 3.
Identify and strengthen weakness in muscles that are pivotal
in the SPF theory such as the peroneus longus or tibialis
posterior.
Depending on dynamic findings, post the forefoot no more
than 3 varus or valgus.
Use semirigid-to-flexible materials. Both allowing and
controlling motion is a central concept.
If early heel lift is a problem, use soft poron heel lifts as
dampeners under the rearfoot post.
Abbreviation: SPF, sagittal plane facilitation.
320 July/August 2009 Vol 99 No 4 Journal of the American Podiatric Medical Association
through the stance phase; 2) to allow the leg to pivot
over the point of ground contact, permitting a normal
stride; and 3) to allow internal and then external rota-
tion of the leg in relation to the ground through STJ
pronation and supination.
A common underlying corrective mechanism may
exist, or there may be more than one way to improve
symptoms with the use of orthoses. We present a the-
ory to explain normal and abnormal foot function,
which can be used to unify and explain benefits re-
portedly obtained from the three established theories.
For the purpose of this article, we discuss methods of
normalizing foot function to improve symptoms rather
than the limitation of normal motion that can be pro-
vided by orthoses to relieve specific symptoms, for
example, the Mortons extension.
53
Theoretical Mechanism for Normal
Foot Function
As the foot hits the ground, initial double-limb stance
occurs. At this stage, the contact phase lower limb, in
relation to the ground, is internally rotating.
54
To allow
this internal rotation, the STJ pronates and the arch
lowers. As the arch lowers, it becomes longer and
structures that originate proximal and insert distal to
the midtarsal joint have increased tension. Relevant
examples of these structures are presented in Table 3.
This increased tension from these structures applies
a longitudinal compressive force through the convex
and concave joints of the midtarsus, theoretically
close-packing these joints and increasing the congru-
ent stability of the foot. In specific relation to the
plantar fascia, a reverse windlass mechanism has
been proposed.
55, 56
Not only does the increased ten-
Table 2. Examples of the Underpinning Theoretical Differences Between Podiatric Foot Function Paradigms
Theoretical Perspective Foot Morphology Theory Sagittal Plane Facilitation Theory Tissue Stress Theory
Criteria for normalcy
Casting methodology
Orthoses aim
Abbreviations: STJ, subtalar joint; STJN, subtalar joint neutral.
sion in the plantar fascia increase the stability of the
midtarsus, it also pulls the digits to the ground be-
cause of the insertion of the plantar fascia into the
digits (Fig. 1). The normal amount of pronation that
occurs with internal leg rotation at contact phase
therefore supplies stability of the foot that is essential
for a normal gait cycle.
Through midstance, the leg begins to externally ro-
tate in relation to the ground.
54
This rotation requires
STJ supination. With this supination, the arch begins
to rise and therefore the origin and insertion of the
structures responsible for aiding the congruent stabil-
ity of the foot become closer and tension could be
lost. This occurs with heel lift, a stage in gait in which
the bodys center of mass progresses anterior to the
ankle over the midtarsal joint.
54
This progression on
center of mass creates a peak moment that attempts
to lower the arch. The ability of the foot to resist
these bending moments and maintain arch raising is
paramount. Unless the slack in any of the plantar
structures can be taken up, stability may be lost.
The windlass effect was first described by Hicks
57
in 1954 and has more recently been expanded on
from different perspectives by Fuller
47
and Danan-
berg.
40
Involved anatomy is that of the medial arch
and medial band of the plantar fascia. The medial
band of the plantar fascia originates from the medial
tubercle of the calcaneus and inserts distally into the
base of the proximal phalanx and sesamoid bones.
58
During closed kinetic chain in a foot with a normal
structure, dorsiflexion of the hallux will tighten the
plantar fascia because of the plantar fascia being
wound around the first metatarsal head. This is analo-
gous to a cable being wound around a windlass.
56
This effectively draws the head of the first metatarsal
The STJ passes through
neutral at key stages of the
gait cycle.
The foot is cast in STJN,
unless a large deformity is a
contraindication.
To prevent abnormal joint
compensation and place the
foot into its normal position for
key stages of the gait cycle.
The foot functions as a pivot
allowing adequate hip
extension and correct posture.
Casting methods are not
documented, although recent
noncustom orthoses from this
theory may eliminate the need
for casting.
To allow the foot to work
successfully as a pivot and
facilitate sagittal plane motion.
The foot functions in a way that
does not result in abnormal
tissue stress and injury.
The positive cast is modified
when taken to supply the shell
shape required to apply the
correct forces to the foot.
To reduce abnormal stress
upon symptomatic structures.
Journal of the American Podiatric Medical Association Vol 99 No 4 July/August 2009 321
and calcaneus together, causing the foot to shorten
and the arch to raise (Fig. 2).
During propulsion, most of the weightbearing is
borne through the medial column of the foot while
the leg is externally rotating and the arch is rising and
shortening. For the heel to lift, the hallux therefore
should dorsiflex. This winds the windlass and main-
tains tension in the plantar fascia, creating a com-
pressive force across the foot. The foot therefore
uses the internal rotation of the leg to aid in its own
stability by increasing plantar structure tension with
pronation through contact and early midstance. As
the foot pivots over the hallux, the leg externally ro-
tates and midfoot stability is maintained through the
windlass mechanism. Although the plantar fascia may
be only one of the many structures involved in main-
taining foot structure in relaxed bipedal stance,
59
it is
theoretically essential in maintaining midtarsus sta-
bility during resupination at heel lift.
Theoretical Mechanism for Abnormal
Foot Function
Failure to be Stable and Maintain a Congruent
Structure through Stance Phase
If moments resisting STJ pronation and arch lowering
are not of significant magnitude, abnormal pronation
may occur and the midtarus may move to a position of
poor congruency through malalignment.
60, 61
Factors
Table 3. Examples of Structures with Theoretically Increased Tension with Lowering of the Arch via STJ Pronation
Structure Origin and Insertion
Plantar fascia Medial tubercle of the calcaneus inserting into the digits. The medial band is the most
substantial and inserts into the proximal phalanx of the hallux.
Long calcaneocuboid ligament Plantar aspect of the calcaneum to the plantar aspect of the cuboid and the bases of the
third, fourth, and fifth metatarsals.
Short calcaneocuboid ligament Plantar anterior tubercle of the calcaneum to the adjoining aspect of the cuboid.
Calcaneonavicular ligament Anterior margin of the sustentaculum tali to the inferior surface and the tuberocity of the
navicular.
Peroneal longus tendon Lateral upper two-thirds of the fibula. The tendon runs forward on the lateral aspect of the
calcaneum around the lateral aspect of the cuboid and inserts into the medial cuneiform
and base of the first metatarsal.
Flexor digitorum longus tendon Posterior surface of the tibia to the bases of the distal phalanges of the lesser digits.
Flexor hallucis longus tendon Posterior surface of the tibia to the base of the distal phalanx of the hallux.
Posterior tibial tendon Posterior surface of the tibia, fibia, and interosseous membrane to the tuberocity of the
navicular and plantar aspects of the cuboid, cuneiforms, and bases of the second, third,
and fourth metatarsals.
Abbreviation: STJ, subtalar joint.
Figure 1. Simple model demonstrating the reverse wind-
lass mechanism.
Figure 2. Simple model demonstrating the dynamic
windlass mechanism.
322 July/August 2009 Vol 99 No 4 Journal of the American Podiatric Medical Association
that either increase pronatory moments or decrease
the foots ability to resist pronatory moments may be
intrinsic to the foot (eg, a medially deviated axis
46
), ex-
trinsic to the foot (eg, weak lateral hip rotators
62
), or
even transient to the foot (eg, ligamentous laxity in
pregnancy
63
).
In addition, for stability to be maintained after heel
lift, the windlass mechanism needs to apply tension
to the plantar fascia. If this fails, the midtarsus will be
unstable at heel lift and unable to resist the bending
moment applied as the heel is pulled off the floor. The
lowering of the arch at heel lift is analogous to STJ
pronation rather than the required supination. For the
windlass to function effectively, dorsiflexion of the
hallux through medial column propulsion must occur.
If a limitation of first MTPJ dorsiflexion is present,
whether structural or functional, a lack of windlass
mechanism may arise with resultant sequelae. A com-
mon compensation mechanism may be to propulse
laterally rather than medially,
40, 64
which has been stat-
ed not only to fail to wind the windlass but also to be
less efficient in propulsion.
65
Although causes of a
structural hallux limitus are well discussed in the lit-
erature,
66-68
the etiology of functional hallux limitus is
less reported. Two possible etiologies are a prolonged
reverse windlass and functional bony restriction of
the first MTPJ. A prolonged reverse windlass occurs
as a result of excessive pronation moments at the
STJ. These excessive moments may be attributable to
a myriad of causes such as a forefoot varus, tibial
varum, or weak lateral hip rotators. The resultant
prolonged reverse windlass results in drawn out plan-
tarflexory moments at the first MTPJ when dorsiflex-
ion should be occurring. Such increased plantarflexo-
ry moments will therefore impede hallux dorsiflexion
and reduce the ability of the foot to propulse through
the first MTPJ. Pressure may remain lateral, engaging
the foot in inefficient propulsion.
64
This, in turn, in-
hibits the arch rising because of the lack of a wind-
lass mechanism.
In a functional bony restriction of the first MTPJ,
dorsiflexion of the first ray impedes the ability of the
first MTPJ to extend.
69
Pronation will lead to dorsi-
flexion of the first ray through increased ground reac-
tion forces to the medial column of the foot.
70
This
will limit the ability of the foot to pivot over the first
MTPJ, leading to sequelae as described with a pro-
longed reverse windlass mechanism. The resultant ef-
fect is similar to that of a structural hallux limitus.
Other possible causes of functional hallux limitus in-
clude sesamoid apparatus failure and fixed elevated
first ray abnormalities.
Failure to Allow the Foot to Pivot and Permit
Normal Stride
The three rockers (round underside of the heel, ankle
dorsiflexion, and hallux dorsiflexion) need to be cor-
rectly timed to coincide with proximally occurring
motion. For example, as the center of mass advances
and the hip extends, the heel must lift appropriately.
54
Failure of the first MTPJ to extend at this vital mo-
ment will impede heel lift and limit hip extension
with consequences up the kinetic chain.
40
For appro-
priate timing of the foot rocker motions, it is essential
that the foot is stable under load, as discussed previ-
ously. Compensation pathways such as a flattened
lordosis and lack of hip and knee extension have
been stated in the literature.
5, 39, 42
Failure to Allow Internal and External Rotation
of the Leg in Relation to the Ground Through
STJ Pronation and Supination
If the STJ has an inadequate range of pronation to
allow normal internal leg rotation at the hip (eg, triple
arthrodesis), normal lumbar and pelvic mechanics
will not occur. The reverse is also true: if there is a
lack of internal rotation at the hip, a normal amount of
STJ pronation may not occur to adequately tense the
plantar structures of the foot and engage the reverse
windlass. An example of this may be a lack of internal
hip rotation demonstrated in osteoarthritic hips.
71
From midstance, in relation to the ground, the leg
externally rotates and applies a supinatory moment
to the STJ. For the leg to externally rotate, the foot
must supinate, and the supinatory moment must be
greater than the pronatory moment across the STJ. In
abnormal situations, this may not occur and can be
attributable to a lack of applied supinatory moments
or increased pronatory moments. There are several
methods by which compensation may occur. The leg
may simply remain internally rotated, or if the friction
coefficient between the floor and the foot is over-
come, the foot may be seen to rapidly abduct and
allow external hip rotation without resupination. This
has been called an abductory twist.
72
Orthotic Prescription Based on the
Unified Theory
The fundamental reason for prescribing functional
foot orthoses is to improve symptomatic gait dysfunc-
tion. This may be caused by one or a combination of
factors resulting in a failure of the foot to function as
a stable pivot or to allow normal transverse plane hip
Journal of the American Podiatric Medical Association Vol 99 No 4 July/August 2009 323
motion. It may be argued that symptomatic gait dys-
function was achieved through previous podiatric
theories, with combinations of negative cast shapes,
varus or valgus posting, or modifications in orthotic
width or extension. For example, TS theory orthotic
prescription would reduce the prolonged windlass by
using varus posting. Sagittal plane facilitation theory
would reduce functional bony restriction of the first
MTPJ by using cut-outs in the shell beneath the first
ray and a kinetic wedge. The FM theory may improve
both of the above abnormalities by varus posting and
a shell cut narrow to 25% of the width of the first ray.
The FM, SPF, and TS theories would all aid the wind-
lass mechanism and improve the foots ability to func-
tion as a stable congruent pivot and assist normal
transverse plane hip rotation. It can, therefore, be
demonstrated by the simple examples above that all
three theories can be conflicting in nature, and yet
coadunate in treatment, by using a unifying theory.
This can also be linked to specific symptom relief.
Plantar fasciitis is one of the most common muscu-
loskeletal injuries presenting to the podiatric physi-
cian and is commonly treated with orthoses.
14
For the
purpose of discussion, we shall assume that the or-
thoses work by reducing excessive tension through
the plantar fascia, correcting timing of both the re-
verse and normal windlass mechanisms, thereby al-
lowing normal gait to occur. The orthotic prescription
based on the FM theory applies posting for feet that
demonstrate abnormal compensation. Beneficial ef-
fects may therefore be explained by the reduction of
abnormal compensation, allowing the foot to func-
tion around the STJN. Alternatively, the device may
be seen to reduce strain in the plantar fascia due to
reduction of excessive pronatory moments placed
across the STJ during the reverse windlass phase.
Therefore, orthoses make it easier for the hallux to
dorsiflex and normal windlass to occur because of a
reduction of plantar fascia stress. In addition, the
classic FM theory orthotic appliance is often cut nar-
row, so that only 25% of the first ray width remains.
This decreases dorsiflexory moments on the first ray
allowing the hallux to dorsiflex more easily and aid
first-ray propulsion. Sagittal plane facilitation theory
and TS theory achieve this benefit in similar ways
while employing particular methods of orthotic con-
struction or modifications. Sagittal plane facilitation
theory uses the kinetic wedge and first-ray cut-outs
as well as minor posting. This reduces strain on the
plantar fascia, decreases dorsiflexory moments on
the first MTPJ via the cut-out, and increases dorsi-
flexory moments on the first MTPJ via the kinetic
wedge. Tissue stress theory advocates the use of
greater posting and the medial heel skive. These in-
crease supinatory moments across the STJ axis and
unload excessive stress in the plantar fascia.
Whether one method is better than the other re-
mains undetermined. Certain orthoses working by a
particular orthotic prescription theory may be better at
correcting certain gait abnormalities or symptoms than
others. However, one might suggest that the relief of
symptoms has always occurred through the improve-
ment of normal foot mechanisms, and the method or
approach to achieve this is inconsequential. Such con-
clusions will depend on research outcomes not yet
available to us.
Conclusions
We have attempted to summarize the available litera-
ture on the three main podiatric theories of gait dys-
function and have proposed a possible unification
theory. Our theory may be seen as an over-simplifica-
tion of orthotic prescription, but it may explain the
fundamental principles behind the apparent universal
success of different approaches to orthotic therapy.
We have not intended to dismiss or prioritize one
method of assessment or treatment over another.
Theoretical issues highlighted within podiatric biome-
chanics are not unique. Other clinical specialties have
conflicting theories of musculoskeletal treatment and
many of these lack evidence.
73, 74
Until greater research is available, each practitioner
should decide which method to use. Podiatric physi-
cians who encompass all approaches may have bene-
fits over those who are more dogmatic. Other determin-
ing factors such as bulk of theory-based appliances,
material durability, and sporting suitability have not
been discussed. As far as the authors are aware, the
perfect foot orthosis has not yet been conceived. It is
hoped that as evidence-based practice becomes more
established, more podiatric physicians and students
will undertake areas of required research related to
the areas highlighted in this article.
Financial Disclosure: None reported.
Conflict of Interest: None reported.
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