Sex Differences in Foot Biomechanics: Implications for Podiatric Practice

Abstract

Biological sex remains an under-recognized but critical determinant in podiatric medicine, significantly influencing foot biomechanics, Achilles tendon (AT) morphology, and plantar pressure distribution. This systematic review aimed to synthesize existing peer-reviewed literature to identify sex-specific differences in AT mechanics and morphology, compare gait patterns and plantar pressure distribution between sexes, and evaluate the clinical implications of these variations for injury prevention and podiatric practice. The findings indicate distinct sexual dimorphisms: males possess larger, stiffer ATs, yet paradoxically face a 2–8 times greater risk of tendon rupture compared to females, whose tendons exhibit lower stiffness and higher compliance driven by hormonal influences like estrogen and relaxin. Furthermore, the prevalence of hallux valgus is substantially higher in females (58%) than in males (25%), attributed to a complex interplay of footwear habits, osseous anatomy, and ligamentous laxity. Biomechanically, females demonstrate higher peak pressures in the hallux and forefoot alongside distinct gait patterns including greater knee valgus and hip abduction whereas males exhibit higher pressure in the lateral forefoot and heel. Ultimately, these results confirm that significant sex-based differences in foot biomechanics and pathology prevalence exist. Therefore, integrating sex as a fundamental biological variable is essential for advancing personalized podiatric assessments, optimizing orthotic prescriptions, and improving clinical rehabilitation outcomes.