December 2, 2008

What is a Forefoot Varus?

This topic is the source of a great deal of misunderstanding. First, lets define some terms:
- “Supinated” and “pronated” are POSITIONS
- “Supination” and “Pronation” are MOTIONS

The whole body supinates and pronates during normal everyday activity. Gravity is trying to squish us into the ground (pronate us) and we resist that force (by supinating). Every step we take causes us to go through pronation and supination at every joint in the body.

The foot is said to be pronated or supinated. This is in reference to the subtalar joint, and specifically to a position called subtalar neutral (where the rear foot is neither pronated nor supinated).

When the forefoot is supinated relative to the rear foot, the condition is referred to as a forefoot varus.

So in other words, when a forefoot is supinated it can appear to be pronated because the body will get the forefoot onto the ground by pronating somewhere. The thing of it is that the pronation that gets the foot on the ground actually occurs higher up the chain as in at the rear foot, the ankle, the knee,the hip or the pelvis and lower back. When this occurs at the subtalar joint, for example,it is not uncommon to see the knees achieve a valgus position (knock kneed).

When a foot APPEARS pronated, one first has to determine if the foot ITSELF is pronated or if it just APPEARS to be pronated. It is easy to confuse the appearance of pronation in the case of a forefoot varus where the forefoot is effectively supinated. The nature of the condition causes failure in teh foot, at the ankle, at the knee and at the hip.

The incidence of this condition is 8% of 116 female subjects (McPoil et al, 1988) and 86% of 120 male and female subjects (Garbalosa et al, 1994).

There are three patterns of compensation:
- uncompensated
- fully compensated
- partially compensated

Forefoot Varus deformities produce numerous associated pathologies, including:

- shin splints
- plantar fasciitis
- tibialis posterior tendonitis
- patello-femoral syndrome
- lesser digital deformity
- hallux abducto valgus
- lower back pain
- sciatica
- metatarsal stress fracture (see Hughes, 1983)

Varus problems are easily treated through the application of Custom Orthotic Therapy.

6 Comments »

  1. Nice blog! So would you say an uncompensated forefoot varus should probably resist wearing vibrams? It seems that if the the forefoot can’t bring the first ray down during propulsion then the either the 1st MTP and/or the plantar fascia will take the hit. Yes no maybe so?
    What are your thoughts on minimalist footwear and Pes Cavus (Rear foot varus and forefoot valgus)

    Thanks,
    Ryan

    Comment by ryan — January 30, 2010 @ 6:40 am

  2. You know Ryan, its not that the uncompensated forefoot should resist wearing vibrams, it’s more that use of the minimal footwear should be more limited in that case because of the increased loading in the joints up the chain. My thought is that the next major joint to suffer would be the patello femoral joint because of the tendency of the tibia to follow the sub-talar joint in the frontal plane. Since you would be running on your forefoot already, the PF should be protected regardless.

    As for rear foot issues and minimal footwear, I think that the rear foot is largely off the ground when running barefoot, and so this should not be an issue. The view point is that the rear foot valgus is compensatory to forefoot issues, and the rear foot varus would be more indicative of a supinated foot in general. In any event you would be on your forefoot so the rear foot issues would be negligible.

    Comment by Neil Chasan, PT, MMT — February 10, 2010 @ 8:56 am

  3. This is interesting…. could it account for a flat-footer showing wear patterns on the outside of the shoe? I am in pretty neutral shoes (ds trainers) but still shoe forefoot wear on the outside (lateral) part of the shoe. Is this overcompensation?

    Comment by ralph — March 3, 2010 @ 10:39 am

  4. If you believe you have a flat foot, AND you show unusual wear on the outside of the forefoot, which is what I take your post to suggest, then I suspect that you might have a forefoot varus or a forefoot supinatus. In my opinion, this would not be overcompensation as you suggest, but just the natural tendency of the forefoot to encounter the ground in its natural posture. In normal wear patterns, we expect to see the transition to the inside of the forefoot begin across the midfoot in normal gait, which would suggest that lateral wear implies lateral contact first…Make sense?

    Comment by Neil Chasan, PT, MMT — March 8, 2010 @ 8:22 am

  5. i am studying for an exam and have looked all over the web for an answer. i suspect the people who wrote these questions are trying to make this harder than it needs to be. her is the question: what type of strain does the deltoid ligament protect the ankle against?
    a. inversion/varus
    b. eversion/varus
    c. eversion/valgus
    d. inversion/valgus

    thank you for your time

    Comment by jennifer lester — August 4, 2010 @ 6:12 pm

  6. c. eversion/valgus…

    Comment by Neil Chasan, PT, MMT — September 1, 2010 @ 9:04 am

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