A question from a doctor on the topic of limb alignment development.

The following question was forwarded to us from an internist on the USA east coast.


“I have a large number of female patients, many of them elderly.  I have noted that women in our society tend to progress to valgus knee deformity with age, and that TKR (total knee replacement) doesn’t seem to correct that deformity. Men tend more to the varus in our society.  I had formerly chalked that up to inherit gender difference.

3 or 4 years ago, I had occasion to spend a lot of time waiting outside the main Tokyo train station and observed a large number of people coming and going.  I observed the following:
1.  Young women had legs that were either straight or varus.
2.  Young women tended toward toeing in.
3.  They did all this in ridiculous high heels.
After some thought, I tend to attribute it to prolonged sitting in sesa (knees folded under), though being barefoot or in slippers while inside may also contribute.  Women in our society sit with their legs crossed.  Additionally, extensive shoe wearing leads to foot pronation.
So, could you direct me to someone who might have an interest in this observation and can refer me to any research that might have been done in this area?  I’ve had the dickens of a time trying to find anything on it, or even a specialized area of study that cares about such things.”


Thanks for your confidence in us. Here are some thoughts:

Frontal plane deformities (or development) is twofold: genetic (and X linked) and developmental. Children usually go through a varus to straight to valgus to straight development (Ron Valmassey talks about this in his text Clinical Biomechanics of the Lower Extremities). Women generally have larger Q angles (from birth) and this angulation often causes assymetrical epiphyseal development (increased pressure on the lateral malleolus/tibial plateau stunts growth) with overgrowth of the medial femoral condyle. Developmental changes are secondary to weight (obesity causes increase in valgus angle) and posture/muscular devlopment. The increased genu valgus places weight medial to the midline (2nd met) of the foot and the foot accomodates by pronating (often excessively, as noted by both of you). This causes medial rotation of the lower leg and thigh, resulting in lengthening of the glutes (esp G max) resulting in stretch weakness and subsequent over reliance on the gastroc/soleus group for propulsion (remember this group tries to invert the heel in an attempt to cause supination once you go past midstance. Weak intrinsics (as pointed out by Dr Mark) further fuels this cycle. “W” sitting (sometimes a cultural development, as pointed out by Dr Birgit) plays in as well.

As for “toeing in”; may women have the combination of genu valgus with internal tibial torsion (often with femoral retroversion) which makes the condition difficult to treat (the rearfoot needs to be supported, but the forefoot needs to be valgus posted) otherwise the knee is placed outside the saggital plane and the meniscus becomes macerated due to conflicting biomechanics at the knee (Thus the short term fix with orthotics with a return of the pain later).

Yes, high heels and open back shoes are evil as are open backed shoes (we spoke at a convention in Chicago a few years back on this, before some of the research was out).

Thanks for allowing us to participate. below are some references for you.

-The GAIT GUYS…….Ivo and Shawn


J Orthop Sports Phys Ther. 2008 Mar;38(3):137-49.

Differences in lower extremity anatomical and postural characteristics in males and females between maturation groups.

Shultz SJ, Nguyen AD, Schmitz RJ.


Applied Neuromechanics Research Laboratory, Department of Exercise and Sport Science, University of North Carolina at Greensboro, 1408 Walker Ave., Greensboro, NC 27402, USA. sjshultz@uncg.edu


When comparing maturation groups, limb length, pelvic angle, and tibial torsion increased with maturation, and anterior knee laxity, genu recurvatum, tibiofemoral angle, and foot pronation decreased with maturation. Females had greater general joint laxity, hip anteversion, and tibiofemoral angles, and shorter femur and tibial lengths than males, regardless of maturation group. Maturational changes in knee laxity and quadriceps angles were sex dependent.


We observed a general change of posture with maturation that began with greater knee valgus, knee recurvatum, and foot pronation in MatGrp1, then moved toward a relative straightening and external rotation of the knee, and supination of the foot in later maturation groups. While the majority of the measures changed similarly in males and females across maturation groups, decreases in quadriceps angles and anterior knee laxity were greater in males compared to females, and females were observed to have a more inwardly rotated hip and valgus knee posture, compared to males, particularly in later maturation groups.


[PubMed – indexed for MEDLINE]


J Bone Joint Surg Br. 1995 Sep;77(5):729-32.

Development of the clinical tibiofemoral angle in normal adolescents. A study of 427 normal subjects from 10 to 16 years of age.

Cahuzac JP, Vardon D, Sales de Gauzy J.


Centre Hospitalier Universitaire de Toulouse-Purpan, France.


We measured the clinical tibiofemoral (TF) angle and the intercondylar (IC) or intermalleolar (IM) distance in 427 normal European children (212 male and 215 female) aged from 10 to 16 years. In our study, girls had a constant valgus (5.5 degrees) and displayed an IM distance of < 8 cm or an IC distance of < 4 cm. By contrast, boys had a varus evolution (4.4 degrees) during the last two years of growth and displayed an IM distance of < 4 cm or an IC distance of < 5 cm. Values above these for genu varum or genu valgum may require careful follow-up and evaluation.

The Psoas Muscle in a Runner: An Endurance Savy Muscle ?

 We received a question yesterday from a doctor. We felt it was worthy of sharing. Here it is, followed by our response.

Doctor:  I do have a question about one of my athletes in particular.  He is a fairly good (All-State in IL) high school track distance runner that has some left sided femoral acetabular impingement.  He gets some capsular hip pain that also will ‘tighten up’ his low back during speed endurance/threshold running only.  Moderate and easy distance runs cause no problem and neither do track/speed workouts.  Only during speed endurance does he have issues.  Upon evaluation after these sessions he does seem to have some low back QL tightness, but joint mobility is fairly good in his lumbar spine.  He does show marked hypertonicity through his left hip joint.  I’m not quite sure the mechanism here- why he would only flare up with speed endurance running- any insights?
Thanks a bunch and I look forward to hearing from you!

The Gait Guys response:

 You state “only during speed endurance” does he have issues. We will assume you mean a long, hard anaerobic workout, which would tax type II b fibers. You also mention he has hypertonicity through his hip joint.  Since the psoas crosses this joint it should be considered in sprinting and long, hard endurance activities, especially if the patient is flexor dominant. The psoas major muscle is composed of type I, IIA and IIX muscle fibers. It has a predominance of type IIA muscle fibers. The fiber type composition of the psoas major muscle was different between levels of its origin starting from the first lumbar to the fourth lumbar vertebra. The psoas major muscle has dynamic and postural functions, which supports the fact that it is the main flexor of the hip joint (dynamic function) and stabilizer of the lumbar spine, sacroiliac and hip joints (postural function). The cranial part of the psoas major muscle has a primarily postural role, whereas the caudal part of the muscle has a dynamic role. This is all very much supported in this journal article here (link) (http://www.ncbi.nlm.nih.gov/pubmed/19930517) and making it work in an endurance capacity would certainly cause issues. Flexor dominance is a common scenario we see clinically, due to insufficient extensor activity (and decreased vestibulo and reticulo spinal drive to extensors) and increased cortico spinal drive (to the flexors, including the iliopsoas). This would fuel the “bail out” (lack of stability) of the lower abs. The anterior tippage of the pelvis would drive the femur posteriorly, binding the joint (the opposite of an anterior femoral glide).

Video footage and some pix of your athlete would provide more insight for us to help.

we are……The Gait Guys

Near Flawless Running Technique…….it would have to be to be doing it at this pace on paved hardtop…….the first fellas techique is better, his step and strike are shorter and thus cadence is higher…….the higher the cadence, the less the acceleration/deceleration and less vertical changes.  Apparently the first chap has been running barefoot his whole life, it shows.  Nicely done boys !

Immediate effects of acupuncture on gait patterns in patients with knee osteoarthritis.

“while no significant changes were found in all the gait variables in the sham group, the experimental group had significant increases in the gait speed, step length, as well as in several components of the joint angles and moments.”

Immediate effects of acupuncture on gait patterns in patients with knee osteoarthritis.

Orthotic Shoe Inserts May Work, but It’s Not Clear Why

Leading orthotics researcher, professor of biomechanics@ Human Performance Lab @ Univ. of Calgary,Alberta. His conclusion: orthotics may be helpful as a short-term solution, preventing injuries in athletes. But it’s not clear how to make inserts that work. The idea that they are supposed to correct mechanical-alignment problems does not hold up. The work of THE GAIT GUYS, hopes to offer some insight.

Ivo Waerlop A potential riff in the article (Via Stu Currie):

1) Primates only have a transverse arch – they are flat in the longitudinal direction.

2) In primates the metatarsal bases are on the same plane as the metatarsal heads.

3) The length of the phalanges is 18% of total foot length in humans, and 35% in chimps.

4) Australopithecus afarensis (Lucy) has the beginning features of a longitudinal arch, while retaining many characteristics of the ape foot. The same can be said for other hominid ancestors (H. Habilus)See MoreJanuary 20 at 7:51am · LikeUnlike

Ivo Waerlop We have always said that orthotics serve as a therapy, not a solution. Your prescription should be getting better (lessening) or more correction taken out with time, not becoming greater. They are an excellent tool, but not a substitue for good mechanics.

Orthotic Shoe Inserts May Work, but It’s Not Clear Why

Shod landing provides enhanced energy dissipation at the knee joint relative to barefoot landing from different heights.

Its great to wear shoes if you are jumping, but not necessarily running. It is interesting that ground reactive forces were not significantly different for shod vs unshod conditions and that that knee flexion, angular velocity and power were higher for those “perceiving” that there would be more cushioning. It goes to show we are not smarter than our brain (we just think we are !).


Knee. 2010 Aug 24. [Epub ahead of print]

Shod landing provides enhanced energy dissipation at the knee joint relative to barefoot landing from different heights.

Yeow CHLee PVGoh JC.

Department of Orthopaedic Surgery, National University of Singapore, Singapore; Division of Bioengineering, National University of Singapore, Singapore.

Shod landing provides enhanced energy dissipation at the knee joint relative to barefoot landing from different heights.

The effect of footwear and sports-surface on dynamic neurological screening (click for link)

Shoes make the man, or in this case, the athlete. This study shows that shoes (much like skis) allow us to perform faster than our brain is able to compensate ( in other words, we lack the skill) and allow us to sometimes stretch our  abilities, often at the cost of an injury. We must remember that technology must keep pace with the rate of neural learning, not the opposite.

J Sci Med Sport. 2010 Jul;13(4):382-6. Epub 2010 Mar 15.

The effect of footwear and sports-surface on dynamic neurological screening (click for link)