足踝临床生物力学治疗与评估-蔡永裕

Fig A
Fig B Fig C
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Pronation
Eversion Abduction Dorsiflexion
Frontal Transverse Sagittal
L E N G T H E N I N G
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RIGHT FOOT
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1. Calcaneal inversion 2. Increased MLA 3. Decreased medial loading 4. External Tibial rotation
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EXCESS PRONATION
足踝臨床生物力學治療與評估
蔡永裕, MS, PT
台中澄清醫院 復健治療部 主任 中國醫藥大學 臨床副教授 昆明醫大 客座教授 陽明大學 高等治療學與手法治療學 講座講師 台灣衛生福利部與教育部 評鑑委員 美國Northwestern University 骨科碩士 澳洲 Vasylimedical 足踝醫療顧問
3 Arches
• Medial Longitudinal Arch: – absorbs the majority of the shock of impact – calcaneus, talus, navicular, cuneiforms, and the first (3) metatarsals. • Lateral Longitudinal Arch: – calcaneus, cuboid, and the fourth and fifth metatarsals. • Transverse Arch: – cuneiforms, the cuboid, and the five metatarsal bases.
鼎足而三
前足 中足 後足
Medial Side
Lateral Side:
Functionally, all the articulations act as one structure. 1. Chopart’s joint (Transverse tarsal) : between posterior segment (talus and calcaneus) and middle segment (navicular and cuboid) 2. Lisfranc’s joint (tarsometatarsal ): between middle and anterior segment.
Link to Sciatic Entrapment
Sway Back
• Bilateral foot pronation both femoral heads are positioned posteriorly which ‘dumps’ the pelvic contents forward increased lumbar lordosis, lumbosacral angle and jamming of the L4-5 and L5-S1 facets. (sway back)
高弓足(旋後足) 扁平足(旋前足)
正常足
高弓足(旋後足)
正常足
扁平足(旋前足)扁平足(旋前足
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內旋(Internal Rotation)
外旋(external Rotation)
扁平足(旋前足)versus高弓足(旋後足)
Neutral
No pronation / supination at the STJ
足弓塌陷的可能后果
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Royal Whitman (1857-1946)
哈佛大学毕业和纽约市的著名骨科医生
• 對“Weak foot 的描述 非常接近我们目前描 述的扁平足。
Plantar Fascitis
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Achilles Tendinitis
Βιβλιοθήκη Baidu
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Femoral Positioning
Right LE: pronated foot internally rotates the left lower extremity, the femoral neck also internally rotates pushes the femoral head posteriorly against the back of the acetabulum Left LE: foot supination, externally rotates the femoral neck The femoral head to push against the anterior part of the acetabulum.
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Tri – Plane Motion
Supination Neutral Pronation
EXTERNAL ROTATION T
INTERNAL ROTATION T
INVERSION F
ADDUCTION T
DORSIFLEXION S
EVERSION F
ABDUCTION T PLANTARFLEXION S
The cervical spine counterbalances the lumbar side bending by side bending right which places the left rectus capitis major posterior muscle on a stretch.
Excess Compensatory Pronation 过多的代偿旋前 Nature v Civilisation
LEFT FOOT
1. Calcaneal eversion 2. Decreased MLA 3 Increased medial loading 4. Internal Tibial rotation
– 惯性，加速度，作用力和反作用 力
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地面反作用力
身體重量
反作用力
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足部的特徵
(Profiles of the Foot)
• ３種型態： 1. NEUTRAL (正中) 2. PRONATION (旋前; 扁平足) 3. SUPINATION (旋後; 高弓足)
不同的足型
(Identifying Foot Type)
Pelvic Rotation
右邊股骨頭(right femoral head)往後推， 而左邊股骨頭往前 推擠髖臼 (acetebulum)
造成骨盆往左旋轉
Excessive pronation pattern of right > left pulls both innominates anteriorly.
Ottawa-Buffalo Ankle guidelines: X-ray or not
• Cannot bear weight for four steps (two steps on each foot) • Have tenderness over the distal 6 cm of the mid third of the distal tibia or fibula. (A & B) • Have point tenderness over the base of the 5th metatarsus (C). • Have point tenderness over the navicular (D).
A functionally short right leg.
The pelvis tilts downward to the right.
The lumbar spine compensates by side bending left which places the right quadratus laborum muscle on a stretch.
• Robbins and Hanna: (1987)
– 赤腳活動相關的感官刺激可能產生肌張力，能 夠提高足弓。而且可能會誘發一個健康的 sustentaculum tali 骨結構改變。 – 肥胖增加了扁平足的潛力，在超重兒童內側縱 弓嚴密監控的發展是必要的，特別是對於4歲至 7歲的兒童。
• Gould:7歲以前(當sustentaculum tali 骨化完全) 足部過度旋前，可以模制sustentaculum tali， 使其不再向下的形成斜坡，支持距骨。
Supination
Inversion
Frontal
Adduction
Transverse
Plantarflexion
Sagittal
Post Tib.
SHORTENING
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Closed Chain Pronation
(站立旋前動作鏈)

Hip: Flex, Add, IR Knee: Flex, Valgus Lower Leg: IR Talus: PF, Add Calcaneus: EV Midtarsal: DF/AB, IV 1st Ray: DF, IV (Loss of MLA) Hallux: Loss of DF
Medial Longitudinal Arch Development
研究指出Medial Longitudinal Arch的發展直到8 歲才完成。而兒童扁平(過度旋前足)，常因膝 外翻(一般是5歲左右)。
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Arch Development
• Rao and Joseph: (1992)
– 穿鞋子兒童中扁平足率較高， – 足弓發展的關鍵期是6歲之前。
內側縱弓Medial Longitudinal Arch
• Formation of a healthy medial longitudinal arch requires the formation of a well-developed sustentaculum tali, a healthy tibialis posterior tendon, an adequate deltoid ligament, a nonconstricted Achilles tendon, and a properly placed inferior calcaneonavicular ligament.
Functional LLD
• Unilateral excessive foot pronation =functional shortening of limb (Sanner et al., 1981)
Anterior rotation of the innominate, if severe enough, can compress the Sciatic Nerve against the greater sciatic notch.

Therefore, it is “normal” that for every step we take on a hard flat UNNATURAL surface for the foot to Excessively Pronate, I.E. go beyond it’s “normal” range of motion.
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Closed Chain Supination (站立旋後動作鏈)

Hip: Ext, Abd, ER Knee: Ext, Varus Lower Leg: ER Talus: DF, Abd Calcaneus: IV Midtarsal: PF/AD, EV 1st Ray: PF, EV (Increased MLA) Hallux: Enhanced DF
Isaac Newton (1642-1727),
英国数学家和物理学家，被许多人认为是有史以来最伟大的 科学家。
•Invented calculus at age 24 •Philosophiae Naturalis 万有引力定律 Principia Mathematica(1686) 其 中载有他的现在著名的三大运 动定律