Prosthetics and Orthotics International

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The Importance of Being Earnest about Shank and Thigh Kinematics Especially When
Using Ankle-Foot Orthoses
Elaine Owen
Prosthet Orthot Int 2010 34: 254
DOI: 10.3109/03093646.2010.485597

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Prosthetics and Orthotics International
September 2010; 34(3): 254–269

The importance of being earnest about shank and thigh

kinematics especially when using ankle-foot orthoses

ELAINE OWEN

Child Development Centre, Bangor, Gwynedd, Wales, UK

Abstract
This paper reviews and summarizes the evidence for important observations of normal and
pathological gait and presents an approach to rehabilitation and orthotic management, which is based
on the significance of shank and thigh kinematics for standing and gait. It discusses normal gait
biomechanics, challenging some traditional beliefs, the interrelationship between segment kinematics,
joint kinematics and kinetics and their relationship to orthotic design, alignment and tuning. It proposes
a description of four rather than three rockers in gait; a simple categorization of pathological gait based
on shank kinematics abnormality; an algorithm for the designing, aligning and tuning of AFO-Footwear
Combinations; and an algorithm for determining the sagittal angle of the ankle in an AFO. It reports the
results of research on Shank to Vertical Angle alignment of tuned AFO-Footwear Combinations and on
the use of ‘point loading’ rocker soles.

Keywords: Biomechanics, gait, lower limb orthotics, physiotherapy, ankle-foot orthosis, ankle-foot
orthosis footwear combination, rockers, categorization of gait disorders

Introduction
Since 1997, the Child Development Centre, Bangor, UK, has routinely used the ORLAU
Video Vector Gait Laboratory to analyze children’s gait and optimize AFO-Footwear
Combination (AFOFC) prescriptions. This has allowed the development of a coherent model
for understanding normal and pathological gait and the designing, aligning and tuning of
AFOFCs.

Normal gait
Understanding biomechanics of normal gait is a prerequisite for successful orthotic
management. Normal and pathological gaits of adults and children have been described
in depth.1–5 While early work described both segment and joint kinematics2 most
modern clinical and research gait analysis has focused on joint kinematics. However,

Correspondence: Ms Elaine Owen, Child Development Centre, Holyhead Road, Bangor, LL57 2EE, Gwynedd, Wales, UK.
E-mail: lugger@talk21.com
This paper was the award-winning ISPO UK 2008 George Murdoch Prize Medal Essay and Lecture.

ISSN 0309-3646 print/ISSN 1746-1553 online Ó 2010 ISPO

DOI: 10.3109/03093646.2010.485597
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 Importance of being earnest about shank and thigh kinematics 255

giving equal weight to the kinematics of both the joints and the segments has wide
importance.

Measurement of joint and segment kinematics

During the gait cycle (GC), movements of the joints of the lower limb are measured as a
continuous series of angles between two segments relative to each other.1,3 When
measuring segments during the GC, their movement needs to be measured in relation to
some position in space.2,5–7 Measurement relative to the vertical can be most helpful as
when standing or walking we have to achieve alignment of the segments relative to the force
of gravity, which is acting vertically. The angle of the segment relative to the vertical can be
measured and described in degrees of incline or recline from the vertical8 (Figure 1). The
term Shank Angle to Floor has been used to describe this angle.8,9 A more accurate term
would be Shank to Vertical Angle10 (SVA). The same terminology would apply to segment
kinematics of the thigh and other segments.

Segment and joint kinematics, traditional beliefs versus reality

Objective measurement of segment kinematics challenges some traditional beliefs. Our
beliefs have pervaded clinical practice and may be one reason why some methods of
intervention are often unsuccessful. Such beliefs may originate from lack of objective data
prior to the availability of slow motion film and other gait analysis systems. The lack of ability
to observe gait accurately may have led us to translate the observed kinematics that we
could see when a subject stands still into beliefs about walking kinematics. However,
evidence suggests the following:

(a) During stance, as seen from the right side, the thigh, shank and foot segments move in
a clockwise direction but not with a uniform angular velocity.2,3,5–7,11–16 During stance
the shank and thigh segments move from a reclined to an inclined position, passing
through vertical. The angular velocity of the shank slows during its movement into
forward inclination in midstance (MST). While the shank is slowing, the thigh angular
velocity increases. The foot becomes stationary in a horizontal position, during MST.

Figure 1. Measurement of segments relative to the vertical.

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256 E. Owen

(b) The shank is not vertical at midstance and there is no place in the gait cycle when both
the shank and thigh are vertical.2,3,5–7,13–16 A common belief is that the shank is
vertical at midstance (MST). This is often combined with a belief that the thigh is also
vertical at this time, and that this is the place in the GC when maximum knee extension
occurs.17 Actually, there is no place in the GC when both the shank and thigh are
vertical (Figure 2). It is, however, possible to demonstrate this scenario in standing. If
we wish to demonstrate standing with fully extended knees we often brace the shank
segment to a vertical position and place the thigh vertically above the shank. This
produces extended knees but, as the hip and knee joint centres are now directly over
the ankle joint, to maintain balance in standing with ease we have to excessively
anteriorly tilt the pelvis, flex the hips and forward lean the trunk. This keeps the ground
reaction force (GRF) in the middle of foot and base of support8 (Figures 3b and 4a).
Those of us with normal balance ability and strength are able to obtain, with effort, a
vertical trunk over the vertical thigh and shank but the GRF at the foot has to move to
the extreme posterior of the base of support. Those with pathology are predominantly
unable to access this option and will have to either adopt the forward trunk lean posture
or recline the thigh whilst also forward leaning the trunk, imposing hip and knee flexion8
(Figure 3a). Normal gait requires an approximately vertical trunk.
Another way to demonstrate standing with fully extended knees is achieved by
inclining the shanks to about 10–128 incline and then moving the pelvis forward so the
thighs are also inclined. The knees will become fully extended and the hips also
extend. The pelvis will remain in normal alignment and the trunk can remain vertical8
(Figures 3f, 4b and 5c). Knee extension is combined with inclined shank and thigh in
normal gait.
(c) The slowing of the shank, in an inclined position of 10–128 incline, during midstance is
important to gait. Midstance is a difficult phase of the GC. The limb is in single stance
and many changes in both kinematics and kinetics occur. The kinematics of the shank
in regard to both its position of incline and its slowed angular velocity during MST is
important for a number of reasons8 (Figure 6).
(1) It contributes to stability in stance (Figure 6). A 10–128 inclined position of the
shank places the knee joint centre over the centre of the foot, which is horizontal
and still at this time.8 This creates a stable distal support mechanism in the form of
a triangle. The concurrent slowing of the shank angular velocity increases this
distal stability.8 Stability in stance is one of the five attributes of normal walking1
and is vital in MST.

Figure 2. Normal gait. Images taken from Video Vector Generator.

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 Importance of being earnest about shank and thigh kinematics 257

Figure 3. Shank kinematics dictate proximal segment kinematics and GRF alignment.8

(2) It facilitates ballistic movement of the thigh, pelvis and trunk. Soleus is restraining
the forward movement of the shank and, with the shank now relatively stationary,
momentum carries the thigh, pelvis and trunk forward to extend the knee.16,18
Perry aptly described this movement as ‘trunk glide’. The angular velocity of the
thigh increases at the time that the angular velocity of the shank decreases.2,6
(3) It dictates thigh, pelvis, trunk and head kinematics.8 An SVA of 10–128 incline is
the optimum position of the shank that allows the thigh to become inclined and the
pelvis and trunk to move forward in a vertical position8 (Figures 3d–f, 5 and 6). If
the shank is vertical the thigh cannot move to an inclined position, unless you can
hyperextend the knee (Figure 3c). If the shank is too inclined then the thigh cannot
become inclined, as the centre of mass within the pelvis would have to move
outside the base of support and balance is lost (Figure 3i and 4c). There is only a
small range of SVA where it is possible to incline the thigh, maintain a vertical
trunk, and balance. It is 7–158 inclined, 10–128 being the optimum position8
(Figures 3f, 4b and 5c).
(4) It facilitates appropriate ground reaction force alignment to the knee and hip and
switching of moments, from flexion to extension moments, at the knee and hip.8,10
The movement of the pelvis and trunk from a position behind the knee to one in
front of the knee, during the trunk glide, moves the centre of mass which is situated
within the pelvis. This facilitates switching of the moments, created by the GRF, at

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258 E. Owen

Figure 4. Positions of the shank and resultant Ground Reaction Forces in standing. Still images taken from ORLAU
Transportable Video Vector Generator.8 (a) SVA vertical/08. Excessive knee extension moments and hip flexion
moments. (b) SVA 10–128 inclined. Appropriate knee and hip extension moments. (c) SVA 208 inclined. Loss of
knee and hip extension moment.

the knee and hip, from flexing to extending moments (Figures 3d–f, 4b and 5a–5c).
Extending moments at the knee and hip are essential for the stability in stance
required at the end of MST and through TST (Figure 7). Appropriately inclined
shanks ensure that appropriate, rather than insufficient or excessive, moments are
created (Figures 3 and 4).
(5) It may contribute to conservation of energy. The inclined position of the shank
shortens the stance limb and lowers the vertical excursion of the centre of mass, at
the time when it is at its highest, which has been linked to conservation of
energy.2,19–22 The flexed knee created at this time from the shank inclination is one
of the six determinants of gait for conservation of energy22 (Figure 6).
(d) Maximum knee extension does not occur in midstance. It occurs at 40% of the gait
cycle in terminal stance, with an inclined shank and thigh. The knee is flexed in
midstance, with an inclined shank. A common belief that the shank and thigh are
vertical in MST with a fully extended knee is erroneous. Maximum knee extension
occurs later in the gait cycle, at 40% GC, in terminal stance (TST)1,3 (Figure 7a).
Maximum hip extension occurs at 50% GC (Figure 7b). The ankle is relatively rigid
through TST, in dorsiflexion, and it is the quasi stiffness of the ankle that permits
maximum hip and knee extension and GRF alignment anterior to the knee and
posterior to the hip, creating stabilizing knee and hip extension moments. Such stability
of the stance leg in TST facilitates full terminal swing of the swing limb and the creation
of ‘the BIG V’ (Figure 7b). Achieving the ‘BIG V’ has consequent benefits of stretching
and strengthening,8,23 ‘therapy while walking’, so improving quality of life (Figure 8).

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 Importance of being earnest about shank and thigh kinematics 259

Figure 5. SVA 128 inclined (a, b, and c) allowing posterior (a) and anterior (c) translation of a vertical trunk. Still
images taken from ORLAU Transportable Video Vector Generator.8 (a) Posterior translation of trunk. Reclined
thigh. Knee flexion and hip flexion moments. Point of application of Ground Reaction Force aligned at posterior foot.
(b) Vertical thigh. Neutral knee and hip moments. Point of application of Ground Reaction Force aligned at centre of
foot. (c) Anterior translation of trunk. Inclined thigh. Knee extension and hip extension moments. Point of application
of Ground Reaction Force aligned at anterior foot.

Figure 6. Knee over middle of foot and slowing of shank. ‘Stability in stance’.8

(e) Shank kinematics are independent of ankle kinematics. The kinematics of the ankle will
adjust to a variety of heel heights automatically.24 However, the shank kinematics
remain the same8 (Figure 9). The exception to this is if one wears very high heels,
when the horizontal projection of the foot becomes shorter.

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260 E. Owen

Figure 7. (a) 40% gait cycle, maximum knee extension. (b) 50% gait cycle, maximum hip extension with knee
extension, inclined shank and thigh, the ‘Big V’.

Figure 8. The ‘Big V’ of terminal stance and terminal swing producing muscle stretches.8 (a) Ankle-Foot Orthosis
Footwear Combination worn on right leg facilitating Terminal Stance and stretching hip, knee, hip flexors and
gastrocnemius. (b) Ankle-Foot Orthosis Footwear Combination worn on left leg facilitating Terminal Stance on left
and consequently Terminal Swing on right and stretching knee, hamstrings and gastrocnemius.

Figure 9. Shank kinematics are independent of ankle kinematics.8

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 Importance of being earnest about shank and thigh kinematics 261

(f) It is helpful to describe four, rather than three, rockers in normal gait.25 Replication of
normal shank kinematics in gait, by orthotic and other interventions, is essential. We
have been taught that the forward progression of the shank is produced by ‘three
rockers’, which require movement at the ankle for the first and second rocker and at the
metatarsophalangeal joints (MTPJs) for the third rocker3 (Figure 10a). The first (heel)
rocker occurs during loading response (LR), the second (ankle) rocker occurs during
MST and the third (forefoot) rocker occurs during both TST and preswing (PSW).3 In
TST the MTPJs extend and this movement is coupled with ‘quasi stiffness’ of the ankle
in dorsiflexion, with hardly any movement3 (Figure 7b). It is this stiffness of the ankle
that facilitates heel rise.3,26 However, in PSW the MTPJs continue to extend but this is
coupled with very rapid movement of the ankle, from the dorsiflexed position at the end
of TST to a plantarflexed position at the end of PSW.3 Dividing the forefoot rocker into a
third rocker in TST and a fourth rocker in PSW25 recognizes the difference in ankle
kinematics in TST compared to PSW.

In pathological gaits all or any of the rockers can be insufficient or excessive. An ideal
design of orthosis would correct the abnormal rocker movements at both the ankle and
MTPJs, during each subdivision of the GC. Because of the different requirements of these
joints during each of the four rockers this is not yet easily possible and compromises have to
be made. We therefore often have to fix the ankle joint and also sometimes the MTPJs. This
prevents use of anatomical rockers and allows us to gain control of the production of the

Figure 10. (a) Forward progression of shank produced by the rockers. (b) Producing normal shank kinematics with
an AFOFC. (c) Producing normal segment and joint kinematics and kinetics with an AFOFC.

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262 E. Owen

shank kinematics by the use of simulated rockers, created by the design of the footwear that
is combined with the ankle-foot orthosis (AFO)8,27 (Figure 10b, 10c). The footwear is
therefore an equally important part of the orthosis and the significance of the part the
footwear plays can be recognized by calling the overall orthosis an AFO-Footwear
Combination.8,28,29

Categorizing the abnormal shank kinematics of pathological gait

Current categorizations of pathological gait are based on joint kinematics.30–37 However, it is
manipulation of the shank segment kinematics, by the AFOFC design, to produce as near
normal shank kinematics as possible, that will be the key to a successful orthotic
intervention.38 Normalization of shank kinematics will facilitate most normal thigh, pelvis and
trunk kinematics and subsequently most normal knee and hip kinematics and kinetics8
(Figure 10b, 10c).
When pathological gait is observed in the sagittal plane there are two basic categories of
abnormal shank kinematics8,27 (Figure 11). These are insufficiently inclined shanks or
excessively inclined shanks during some or all of the subdivisions of the GC. In addition,
some pathological gaits may even combine these abnormalities in one GC, for example
excessive incline followed by insufficient incline.
Following the principle that different designs of AFOFCs will be needed to normalize such
different gait abnormalities, it is possible to create an algorithm for the design and tuning of
an AFOFC based on shank kinematics27 (Figure 12). The importance of basing the
algorithm on shank kinematics is that we concentrate on correcting insufficient or excessive
shank incline, at the times in the GC that these abnormalities occur. This is a different
approach to that of concentrating on correcting the movement of the joints, which will not
necessarily correct shank kinematics.

An algorithm for design and tuning AFO-footwear combinations based on shank

kinematics27
This algorithm is based on 11 years of experience of designing and tuning AFOFCs for a
population of children with cerebral palsy, spina bifida and other conditions on the ORLAU
transportable Video Vector Generator Gait Laboratory. This provides a video recording of
gait together with simultaneous visualization of the GRF which is superimposed on the video
image. It has freeze frame and slow motion facilities.39–41 Pathological gait can be analyzed
and AFOFC designs optimized to produce objective normalization of both the kinematics
and kinetics of gait. Some aspects of the algorithm and research results challenge traditional
beliefs. It also introduces AFOFC designs that make prescriptions more effective.

(a) Hinged versus fixed. The algorithm starts with observation of the stance phase of gait,
to determine whether shank kinematics are normal. If not, a fixed ankle AFO is
recommended because strong orthotic control of the ankle is required if the shank
kinematics are to be controlled sufficiently to enable control of more proximal segment
and joint kinematics and kinetics. AFOFCs with hinges are inadequate, when the shank
kinematics cannot be controlled, and superfluous, when the hinges are not used once
the AFOFC is tuned.
(b) The Angle of the Ankle in the AFO (AA-AFO) and the Shank to Vertical Angle of
the AFOFC are independent. It is theoretically possible to create any SVA with any
AA-AFO by alteration of the pitch/’heel sole differential’ of the footwear8 (Figures 12

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 Importance of being earnest about shank and thigh kinematics 263

Figure 11. Abnormalities of shank kinematics in pathological gait.8

and 13). There is often a belief that the SVA and AA-AFO are inextricably linked, it
being assumed that it is only possible to alter one by altering the other (Figure 13a,
13e, 13i). This belief can confound and invalidate research.
(c) There is poor recognition of the differentiation between AA-AFO and the SVA in the
literature. A search of 310 publications8 found that only nine differentiated and
contained sufficient information to determine the SVAs used.28,42–48 Of these only
three included gait trials of a variety of SVAs to support their findings.28,45,48
(d) A prerequisite for successful interventions and tuning of AFOFCs is an optimal AA-
AFO. Common beliefs are that the AA-AFO must always be 908 or that dorsiflexion and
plantigrade positions are acceptable, but not plantarflexion. The belief about 908 may
have come from the belief that the shank must be vertical to obtain straight knees when
walking. Optimal AFOFCs use a variety of AA-AFO and the use of plantarflexion may
be essential.49 In addition, a plantarflexed AA-AFO may increase musculotendinous
unit length, facilitate knee extension in gait, allow the musculotendinous unit to be at

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264 E. Owen

Figure 12. A clinical algorithm for the design and tuning of ankle-foot orthosis footwear combinations (AFOFCs)
based on shank kinematics.

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 Importance of being earnest about shank and thigh kinematics 265

Figure 13. Nine theoretical configurations of the Angle of the Ankle in the Ankle-Foot Orthosis and the SVA of an
Ankle-Foot Orthosis Footwear Combination.8

the optimum length for force production and prevent the development of bony foot
deformities caused by enforced supination or pronation within the AFO49 (Figure 14).
The use of plantarflexed AA-AFO to gain musculotendinous unit length is counter-
intuitive but does occur.20,21 There are a number of considerations that are involved in
determining the optimal angle. These have been described in a separate algorithm.49
The starting point of the algorithm is the measured length of the gastrocnemius muscle,
measured with the knee extended and the foot dorsiflexed. This measure will vary
according to whether the foot is pronated, supinated or neutral. The algorithm
recommends that the position with the least amount of range is chosen as a starting
measure. For feet that ‘escape’ into pronation, the supinated range will be the starting
measure. For feet that escape into supination, the neutral position will often be the
measure. The algorithm incorporates opportunities for interventions but frequently
clinicians are left with difficult decisions that are very individual for each leg of each
patient.
(e) Shank alignment needs to be more inclined than it has been traditionally, for children at
least. Our work has been the only study that has optimally tuned, using combined
kinematics and kinetic gait analysis, the SVAs of the AFOFCs of a population of
independently ambulant children, walking without aids, with cerebral palsy, spina bifida

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266 E. Owen

and other, mainly neurological, conditions.8,9 The study showed that the tuned SVAs of
74 children using 112 AFOFCs, range from 7–158 incline with a mean of 11.368 (Figure
15). There is therefore a match between the mean SVA of the tuned AFOFCs and the
mean SVA in MST of barefoot normal gait and 10–128 is a good place to start when
tuning the SVA. No children had optimal SVA of 0–68. The SVAs were more inclined
than the traditional 0–78 setting. Other studies are now concurring with our
findings.7,50,51 Tuned AFOFCs place the SVA in the optimal position in MST and
also provide the slowing of the angular velocity of the shank, both of which are required
to replicate the distal stability of normal shank kinematics.
(f) The literature does not recognize the importance of tuning/optimizing the SVA of an
AFOFC. A search of 310 publications8 found that only 22 alluded to the importance of
the SVA of an AFOFC and/or tuning.19–21,43–48,52–61

Figure 14. Proposed clinical algorithm for deciding the sagittal angle of the ankle in an ankle-foot orthosis footwear
combination.

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 Importance of being earnest about shank and thigh kinematics 267

Figure 15. Frequency distribution graph of SVA of tuned AFOFCs by diagnosis.8

(g) Point Loading Rockers27,28,45,62,63 are almost always essential if gait with excessively
inclined shanks is to be controlled. For a ‘Point Loading Rocker’ (PLR) to be effective,
the sole must be very stiff and completely flat until the rocker, there must be an
acute angle at the position of the rocker and sufficient toe spring angle27,62,63
(Figure 12). The position of PLRs, and the accompanying toe spring angles, optimized
by kinematic and kinetic tuning, has been determined for AFOFCs used on 23 legs of
children with disability.62 The PLR length mean was 78% (range 70–88%). So, when
tuning a PLR a good starting point is to position it at 80/85% along the length of the
footwear and move it backwards or forwards as required. Mean toe spring angle was
338 (range 18–508).

Conclusion
This paper has attempted to show why it is important to be earnest about shank and thigh
kinematics, especially when using AFOFCs, whatever the objectives for their use. These
may include improvement in standing balance, gait, activity and participation; development
of normal segment kinematics and motor learning;48,52,53,58 prevention or improvement of
bony and joint deformity; normalization of muscle length, strength and stiffness.

Declaration of interest: The author reports no conflicts of interest. The author alone is
responsible for the content and writing of the paper.

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