Manual Therapy 20 (2015) 79e83

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

The effects of forefoot varus on hip and knee kinematics during

single-leg squat*

bio V. Serra
~o a, *
Rodrigo Scattone Silva a, Carlos D. Maciel b, Fa
a
b

~o Carlos, Department of Physical Therapy, Sa

~o Carlos, SP, Brazil
Federal University of Sa
~o Paulo, Department of Electrical Engineering, Sa
~o Carlos, SP, Brazil
University of Sa

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 18 November 2013
Received in revised form
15 May 2014
Accepted 4 July 2014

Foot misalignments, such as forefoot varus (FV), have been associated with musculoskeletal injuries in
the proximal joints of the lower limb. Previous theories suggested that this association occurs because FV
inuences knee and hip kinematics during closed kinetic chain activities. However, research on the effects of FV in the kinematics of the lower limb is very scarce. Therefore, the purpose of this study was to
compare the knee and hip kinematics between subjects with and without FV during a functional weightbearing activity. Forty-six healthy adolescents were divided into two groups: group of subjects with FV
(VG, n 23) and group of subjects with aligned forefoot (CG, n 23). A kinematic evaluation was
conducted while the subjects performed a single-leg squat task. The variables of interest were hip internal rotation and adduction and knee abduction excursions at 15 , 30 , 45 and 60 of knee exion.
Between-group comparisons were performed with multivariate analysis of variance. Results showed that
the VG presented greater hip internal rotation when compared with the CG across all evaluated knee
exion angles (P 0.02e0.0001). No differences between groups were observed in hip adduction or knee
abduction (P > 0.05). These results indicate that FV inuences the transverse plane hip movement
patterns during a functional weight-bearing activity. Considering that excessive hip internal rotation has
been associated with knee injuries, these ndings might contribute for a better understanding of the link
between FV and injuries of the proximal joints of the lower limb.
2014 Elsevier Ltd. All rights reserved.

Keywords:
Subtalar hyperpronation
Patellofemoral pain
Biomechanics

1. Introduction
Alterations in the foot mechanics during weight-bearing activities may affect the movement patterns of proximal joints, predisposing to the occurrence of overload injuries (Fonseca et al., 2007).
Forefoot varus (FV) is a foot misalignment in which the plane of the
metatarsal heads is supinated in relation to the rearfoot when the
subtalar joint is xed in a neutral position (Root et al., 1977). It is
believed that FV increases the pronation of the subtalar joint
(subtalar hyperpronation) during foot stance, to allow the medial
metatarsals to contact the oor (Alonso-V

azquez et al., 2009).
Therefore, this forefoot misalignment may produce signicant
compensations in other body segments and may have important

*
The protocol for this study was approved by the Federal University of S~
ao Carlos
Institutional Review Board and supported by the Coordena~
ao de Aperfeioamento
de Pessoal de Nvel Superior (CAPES) and the Funda~
ao de Amparo a Pesquisa do
~o Paulo (FAPESP).
Estado de Sa
~o Carlos, Department of Physical
* Corresponding author. Federal University of Sa
~o Carlos, SP, Brazil.
Therapy, Rod. Washington Lus, Km 235 e CEP 13.565-905, Sa
~o).
E-mail address: fserrao@ufscar.br (F.V. Serra

http://dx.doi.org/10.1016/j.math.2014.07.001
1356-689X/ 2014 Elsevier Ltd. All rights reserved.

clinical relevance, especially considering that an association has

been observed between FV and injuries in the knee (Lun et al.,
2004), hip (Gross et al., 2007), and lumbar spine (Rothbart et al.,
1995).
Subtalar joint pronation is a triplanar motion composed of
calcaneus eversion and talus plantar exion and internal rotation.
Because the talus is rmly stabilized by the ankle mortise, subtalar
joint pronation is necessarily associated with tibial internal rotation
in closed kinetic chain (Rockar, 1995). Therefore, excessive subtalar
joint pronation is believed to result in increased lower limb internal
rotation during weight-bearing activities (Tiberio, 1987). Also, it has
been proposed that a greater calcaneal eversion, associated with
subtalar hyperpronation, could result in increased knee abduction
in closed kinetic chain activities (Gross, 1995). It has been theorized
that these proximal compensations, associated with foot misalignments, could signicantly inuence patellofemoral joint mechanics and contribute to the development of patellofemoral pain
(PFP) (Tiberio, 1987; Powers, 2003). Supporting these theories,
prospective studies have demonstrated that FV and subtalar
hyperpronation are risk factors for the development of PFP (Lun
et al., 2004; Boling et al., 2009). However, very few studies have

80

R. Scattone Silva et al. / Manual Therapy 20 (2015) 79e83

attempted to verify whether FV and subtalar hyperpronation are, in

fact, associated with altered movement patterns in the knee and
hip joints.
There is some evidence conrming an association between foot
misalignments and altered movement patterns in the lower limbs.
Previous studies have demonstrated that inducing subtalar hyperpronation in subjects with aligned feet indeed produces kinematic
alterations in the tibia and femur in gait (Lafortune et al., 1994;
Souza et al., 2009). However, these studies have veried the acute
effects of inducing foot misalignments in subjects with aligned feet.
To our knowledge, the only studies that have included lower limb
kinematic evaluations of subjects who actually present FV, were

zquez et al., 2009) or restricted
conducted with children (Alonso-Va
the evaluation to the knee joint (Bittencourt et al., 2012). Therefore,
the effects of this forefoot misalignment in the movement patterns
of other segments, such as the hip joint, in subjects other than
children, are still unknown.
Lastly, previous studies that have attempted to verify the inuence of foot misalignments on lower limb biomechanics have
included kinematic evaluations during gait (Lafortune et al., 1994;

zquez et al., 2009; Souza et al., 2009). However,
Alonso-Va
research on the effects of FV on lower limb kinematics during other
functional activities, such as the single-leg squat, is still scarce
(Bittencourt et al., 2012). The identication of altered movement
patterns in subjects with FV could provide better justication for
the use of foot orthosis as an intervention for rehabilitation and
prevention of injuries. Therefore, the purpose of this study was to
compare the hip and knee kinematics between adolescents with
and without FV during a single-leg squat task. It was hypothesized
that subjects with FV would present greater hip internal rotation
and greater knee abduction when compared with subjects with
aligned forefoot.
2. Methods
2.1. Subjects
Forty-six healthy asymptomatic subjects, 14e18 years of age,
volunteered for this study and were divided into two groups: group
of subjects with compensated forefoot varus (VG, n 23, 11 male,
12 female) and group of subjects with neutral forefoot alignment
(CG, n 23, 11 male, 12 female). The presence of compensated
forefoot varus was established if the subject presented an angle of
forefoot varus 8 and a weight-bearing rearfoot eversion angle
10 (Buchanan and Davis, 2005). The decision of including the
rearfoot angle as an additional inclusion criterion was made to
ensure that the included subjects presented subtalar hyperpronation. It would be unlikely that FV would inuence the proximal segments of the kinetic chain if no compensatory subtalar
hyperpronation were occurring (Hlavac, 1970; Tiberio, 1988).
Calculations regarding sample size were conducted a priori using the Statistica software (StatSoft Inc, Tulsa, USA). Hip internal
rotation excursion was considered the primary outcome. The calculations were made using a .05, b .20, an expected difference
between groups of 4.3 , and a within-group standard deviation of
5.0 . These parameters were based on the ndings of previous
research (Nakagawa et al., 2012). Based on these parameters, 23
subjects per group were required to adequately power the study for
this variable of interest.
Adolescents were recruited considering that subjects in this life
stage present a very high prevalence of knee dysfunctions, and
these dysfunctions have been related to foot misalignments
(Mlgaard et al., 2011). The following exclusion criteria were
established for this study: 1) injury to either lower extremity in the
previous 6 months; 2) history of congenital deformity or surgery in

the lower extremities; 3) regular practice of physical activity, in a

frequency of 3 times per week or greater; 4) presence of valgus
forefoot; 5) presence of neurological or systemic conditions that
could impair the participant's ability to perform the proposed
evaluations. The subjects were recruited from local high-schools
and were invited to participate in the study, which was approved
by the Ethics Committee of the University. Each volunteer signed an
informed consent form. Parental or guardian consent was also
obtained for the volunteers younger than 18 years of age.
2.2. Procedures
Research on the effects of FV on lower limb biomechanics has
increased in the last few decades. In that context, several traditional
and innovative ways for evaluating forefoot alignment have been
utilized and include evaluations using laser technology (Chen et al.,
2003), camera systems (Gross et al., 2007; Monaghan et al., 2013)
and clinical evaluations using a standard goniometer (Root et al.,
1979). In the current study, a standard goniometric evaluation
was chosen due to the fact that this evaluation can more easily be
performed in the clinical setting. Also, previous studies have
already demonstrated that greater values of FV, identied by this
goniometric evaluation, are associated with other measurements
for identifying subtalar hyperpronation, such as the rearfoot eversion test (Buchanan and Davis, 2005; Johanson et al., 2010; Scattone
Silva et al., in press), the navicular drop test (Buchanan and Davis,
2005; Scattone Silva et al., in press) and the Foot Posture Index
(Scattone Silva et al., in press).
For this forefoot alignment evaluation, the subjects were positioned in prone lying, with the hip of the evaluated limb in a neutral
position and the knee extended. The other lower limb was positioned in hip abduction and external rotation, with 90 of knee
exion. In this position, lines were drawn bisecting the lower third
of the leg and the calcaneus (Buchanan and Davis, 2005). The
subtalar joint was held in a neutral position for the forefoot
alignment measurement, as previously performed by Elveru et al.
(1988). A universal goniometer was used for measuring forefoot
alignment. One hand of the examiner held the subject's subtalar
joint in its neutral position, and the other hand was used to align
the goniometer so that the xed arm was positioned perpendicular
to the bisection of the calcaneus, and the moveable arm was aligned
with an imaginary line drawn through the metatarsal heads
(Buchanan and Davis, 2005). Both lower limbs were evaluated in a
random order.
Then, the subject was positioned standing on a 45.0 cm-high
step that was positioned close to a wall, for the assessment of the
rearfoot angle. The rearfoot angle was assessed with a universal
goniometer with the subject in a single-leg relaxed stance. The
subject was instructed to ex the opposite knee and was allowed to
touch the wall with both hands for balance, if necessary. The angle
between the bisection of the lower third of the leg and the bisection
of the calcaneus was recorded (Buchanan and Davis, 2005). Three
measurements of the forefoot and rearfoot alignments were taken
and average values were calculated for analysis. For greater reliability, the same examiner performed all foot alignment
assessments.
A previous study, using the same methodology, tested the reliability of these measurements of foot alignment in 15 healthy adolescents. In this study, the intraclass correlation coefcients
(ICC3,3) and the standard error of measurement of the forefoot
varus angle and the rearfoot angle measurements were 0.99 (0.55 )
and 0.94 (0.89 ), respectively (Scattone Silva et al., 2013), indicating
that these measurements are reliable.
Next, for the subjects in the VG, the lower limb presenting FV
was submitted to a kinematic evaluation. For subjects with bilateral

R. Scattone Silva et al. / Manual Therapy 20 (2015) 79e83

FV, the limb with greater forefoot misalignment was submitted to

the kinematic evaluation. The subjects from the CG were matched
to the subjects from the VG regarding anthropometric variables and
regarding the lower limb that would be submitted to the kinematic
evaluation.
Three-dimensional kinematics of the hip and knee were
assessed through electromagnetic tracking with the Flock of Birds
hardware (Ascension Technology Corporation, Burlington, USA)
integrated with the MotionMonitor software (Innovative Sports
Training, Chicago, USA) at a sampling rate of 90 Hz. For this
assessment, four electromagnetic sensors were attached to the
sacrum (S2), the distal lateral thighs and the anteromedial aspect of
the proximal tibia using double-sided tape and adhesive tape
(Nakagawa et al., 2012). The subjects were barefoot during the
evaluation. The medial and lateral malleoli and femoral epicondyles
were digitized to determine the ankle joint center and knee joint
center, respectively. The hip joint center was estimated using the
functional approach described by Leardini et al. (1999). Afterward, a
static le was taken with the subject in anatomic position, for the
determination of the neutral alignment angles of the joints.
Then, the subjects were instructed to stand on their evaluated
lower limb, with 90 of knee exion in the contralateral lower limb
and their arms crossed over their chests for the determination of
the hip and knee angles in the single-leg stance. Three static
standing trials were recorded and used to determine the lower limb
single-leg anatomical position.
For the performance of the single-leg squat task, the subject was
instructed to ex the knee of the non-tested limb to 90 and cross
the arms over the chest. The subject was then instructed to squat
down as far as possible during a 2-s period and then return to a
single-legged stand during a further 2-s period, monitored using a
digital metronome (Nakagawa et al., 2012). The task was performed
at least 3 times before data collection for familiarization. Next,
three valid trials were collected for analysis with 1-min of rest
between the trials, to prevent fatigue. A trial was considered valid if
the subjects performed the single-leg squat with at least 60 of
knee exion within a 4-s period without losing their balance.
A prior reliability study, using the same methodology for the
kinematic evaluation, veried high between-section intrarater
reliability for the variables of interest of this study. Specically, the
intraclass correlation coefcients (ICC3,1) and standard error of
measurements were 0.89 (1.75 ) for hip internal rotation, 0.96
(1.52 ) for hip adduction, and 0.92 (1.33 ) for knee abduction
(Nakagawa et al., 2014).

2.3. Data analysis

The kinematic data were ltered using a fourth-order, zero-lag,
low-pass Butterworth lter at 6 Hz. The Euler angles were calculated using the joint coordinate systems denitions recommended
by the International Society of Biomechanics (Wu et al., 2002) using
the MotionMonitor software. The variables of interest were the
excursions of hip internal rotation, hip adduction and knee
abduction at 15 , 30 , 45 , and 60 of knee exion during the
downward and upward phases of the single-leg squat task.
The hip and knee kinematic variables represented the movement excursions, which were calculated by subtraction of the
values acquired during the cited knee exion angles from those
recorded in the static standing single-leg position. The kinematic
data were reduced using custom MATLAB software (MathWorks,
Natick, USA).
The data were analyzed with respect to their statistical distribution and variance homogeneity using the ShapiroeWilk and
Levene tests, respectively. Independent t-tests were conducted to

81

identify group differences with regard to age, body mass, height,

body mass index, forefoot varus angle and rearfoot angle.
The hip and knee kinematics data were compared between
groups using a one-way multivariate analysis of variance (MANOVA) to determine the effect of group (forefoot varus and control)
on hip internal rotation and adduction and knee abduction at 15 ,
30 , 45 , and 60 of knee exion during the downward and upward
phases of the task. Univariate tests were conducted as follow-up
tests to the MANOVA on each dependent variable. For all statistical tests, SPSS software (SPSS Inc, Chicago, USA) was used and the a
level was preset at 0.05.
3. Results
Results showed no differences between groups with regard to
age, body mass, height and body mass index (P > 0.05) (Table 1).
The foot alignment data analysis revealed that, as expected, the VG
presented higher values of forefoot varus angle (mean
difference 7.46 ; 95% condence interval [95% CI] 6.06, 8.45;
P < 0.001) and higher values of rearfoot angle (mean
difference 9.11 ; 95% CI 7.14, 11.07; P < 0.001) (Table 1) when
compared with the CG.
Regarding hip and knee kinematic during the descending and
ascending phases of the single-leg squat task, the MANOVA identied a signicant group effect (Wilks' l 0.256, F 2.540,
P 0.017), and the follow-up univariate tests revealed that the VG
presented greater hip internal rotation than the CG across all knee
exion angles, in both the descending and the ascending phases of
the single-leg squat (P 0.02e0.0001) (Fig. 1). With regard to hip
adduction and knee abduction, no signicant group differences
were observed (P > 0.05) (Figs. 2 and 3).
4. Discussion
The exact effects of FV in the mechanics of proximal joints
during dynamic weight-bearing activities are not yet clear. Recent
research suggests that FV increases the amplitude and duration of
foot pronation during gait (Monaghan et al., 2013). Also, other
studies have observed a signicant coupling between forefoot and
rearfoot movements (Eslami et al., 2007; Chang et al., 2008; Pohl
and Buckley, 2008) and between rearfoot eversion and tibial and
femoral movements, especially in the transverse plane, during
walking and running (Eslami et al., 2007; Pohl and Buckley, 2008;
Souza et al., 2010). These ndings indicate that alterations in the
forefoot alignment and mechanics might produce compensations
in the proximal joints of the lower limb.
Our results showed that subjects with FV presented greater hip
internal rotation excursion than subjects with aligned forefoot
when performing a single-leg squat task, partially supporting our
hypothesis. In agreement with our results, a previous study
observed greater hip internal rotation during gait in young adults
wearing sandals with lateral wedges, to induce FV (Souza et al.,

zquez et al. (2009) observed no
2009). Conversely, Alonso-Va
Table 1
Sample demographic characteristics and foot alignment data (mean standard
deviation).
Forefoot varus
group (n 23)
Age (y)
Body mass (kg)
Height (m)
Body mass index (kg/m2)
Forefoot varus angle ( )
Rearfoot angle ( )
a

16.70
59.71
1.67
21.27
10.94
14.95

1.02
7.78
0.10
1.62
2.52a
3.71a

Control group
(n 23)
16.22
61.70
1.70
21.32
3.48
5.84

Signicantly different in comparison to the control group (P < 0.001).

1.57
10.51
0.08
2.06
2.15
2.84

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R. Scattone Silva et al. / Manual Therapy 20 (2015) 79e83

Fig. 1. Hip internal rotation excursion at 15 , 30 , 45 and 60 of knee exion during
the downward and upward phases of the single-leg squat task, for subjects with and
without forefoot varus (mean standard deviation). *P < 0.05.

difference in hip internal rotation during gait between children

with and without FV. These results might indicate that the effects of
FV on lower limb transverse plane movements are not yet evident
in children. Nevertheless, our results indicate that, in adolescents,
these effects are already evident during a weight-bearing functional task.
Proximal compensations associated with foot misalignments
seem to occur due to direct mechanical ascending effects. For
instance, a few studies have shown that inducing subtalar hyperpronation in subjects with aligned feet (increasing calcaneal eversion using lateral wedges) results in increased knee and hip internal
rotation (Khamis and Yizhar, 2007; Tateuchi et al., 2011) and pelvic
anteversion (Khamis and Yizhar, 2007) in orthostatic stance. The
presence of such compensations also raises the question on
whether or not foot misalignments, such as FV, result in proximal
effects regarding motor control. Interestingly, previous studies have
shown that subjects with FV have weaker hip muscles (Scattone

Fig. 2. Hip adduction excursion at 15 , 30 , 45 and 60 of knee exion during the
downward and upward phases of the single-leg squat task, for subjects with and
without forefoot varus (mean standard deviation).

Fig. 3. Knee abduction excursion at 15 , 30 , 45 and 60 of knee exion during the
downward and upward phases of the single-leg squat task, for subjects with and
without forefoot varus (mean standard deviation).

Silva et al., 2013) and altered anteroposterior postural stability

(Cobb et al., 2004). These results indicate that foot misalignments
might also inuence the strength generation capacity of muscles
acting on proximal joints.
Regarding frontal plane hip movements, no difference was
observed in hip adduction between subjects with and without FV
while performing the single-leg squat. To our knowledge, only the
study from Alonso-V

azquez et al. (2009) compared frontal plane
hip kinematics between subjects with FV and controls. Their study
demonstrated that children with FV presented less hip adduction
than children without FV in the stance phase of gait. The authors
supposed that this smaller hip adduction occurred in order to
prevent an excessive medial displacement of the lower limb that
could be associated with FV and subtalar hyperpronation (Alonso
zquez et al., 2009). These conicting results might be due to
Va
methodological differences, especially regarding the evaluated
task. The single-leg squat is a more demanding task, when
compared with gait. Therefore, the subjects from our study may
have used compensatory strategies in trunk and pelvis movements,
in order to prevent excessive hip adduction. However, a kinematic
evaluation including these body segments is necessary to conrm
this hypothesis.
Concerning knee kinematics, it was expected that subjects with
FV would present greater knee abduction than subjects with aligned
forefoot (Gross, 1995). However, our results showed no difference in
knee abduction between subjects with and without FV during the
single-leg squat task. Bittencourt et al. (2012) recently performed a
study to verify which factors, proximal and distal to the knee, were
able to predict altered frontal plane knee mechanics in young athletes during single-leg squat and jump-landing. In agreement with
our results, the authors found no association between FV and altered
frontal plane knee mechanics during single-leg squat. However,
during the jump-landing task, the authors observed that the FV
variable was able to predict increased frontal plane knee projection
angles in these athletes (Bittencourt et al., 2012).
The results from the study by Bittencourt et al. (2012) suggested
that altered frontal plane knee mechanics are inuenced by several
factors, proximal and distal. Also, it appears that the effects of these
factors are not the same in different weight-bearing tasks.
Considering that in the single-leg squat the foot is already in contact with the oor from the beginning of the task, it is possible that
foot alignment has a smaller inuence on knee mechanics during

R. Scattone Silva et al. / Manual Therapy 20 (2015) 79e83

tasks of this nature. Conversely, for tasks in which foot contact

occurs at a higher velocity (i.e., jump-landing, running), the
excessive calcaneus eversion, that is secondary to FV, might have a
greater inuence in producing knee abduction. Supporting this
hypothesis, Joseph et al. (2008) observed that the use of foot
orthosis with medial posts, to prevent excessive calcaneus eversion,
resulted in less knee abduction during jump-landings in female
athletes. Further research is warranted to reach a better understanding of the effects of foot misalignments on the proximal
segments of the kinetic chain and on the association between these
effects and injuries.
The present study had limitations. The kinematic evaluation was
restricted to the hip and knee joints. The inclusion of trunk and
pelvis kinematics could provide additional insight about the
possible compensatory strategies adopted during the task. Also,
although the rearfoot eversion test is a commonly used test to
measure how pronated the foot is, this test might not be the best
indicator of the presence or absence of subtalar hyperpronation due
to potential poor sensitivity and/or specicity. Lastly, considering
the cross-sectional nature of this study, it cannot be established
that FV is the cause of the observed increased hip internal rotation
movement. One could argue that the increased hip internal rotation
could inuence forefoot alignment. However, it is believed that FV
is a congenital bony abnormality that originates in the failure of the
talar neck to derotate from its fetal position (Sgarlato, 1971).
Therefore, it seems more likely that the greater hip internal rotation
observed in the present study is, in fact, a consequence of the
forefoot malalignment. Future studies should look into the effects
of foot orthosis, including medial posts for correcting FV, in
reducing this increased hip internal rotation movements during
functional activities.
5. Conclusion
Movement pattern alterations on the hip in the transverse plane
were observed in young subjects with FV when compared with
subjects with aligned forefoot during a single-leg squat. The VG
presented greater hip internal rotation excursion when compared
with the CG during all stages of the task. These results indicate that
forefoot misalignments are associated with movement pattern alterations in the proximal joints of the lower limb, and might
contribute to a better understanding of the link between foot
misalignments and injuries in the knee, hip and lumbar spine.
Acknowledgments
The authors gratefully acknowledge the nancial support from the
~o de Aperfeioamento de Pessoal de Nvel Superior (CAPES)
Coordenaa
~o de Amparo a Pesquisa do Estado de Sa
~o Paulo
and the Fundaa
(FAPESP). The authors would also like to thank Ana Luisa Granado
Ferreira and Lvia Maria Veronese for their help in the evaluations.
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