1、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 前足 中足 後足鼎足而三Medial Side Lateral Side: Functionally, all the articulations act as one structure.1. Choparts joint (Transverse tarsal) : between poster
2、ior segment (talus and calcaneus) and middle segment (navicular and cuboid) 2. Lisfrancs joint (tarsometatarsal ): between middle and anterior segment.Ottawa-Buffalo Ankle guidelines: X-ray or notCannot bear weight for four steps (two steps on each foot) Have tenderness over the distal 6 cm of the m
3、id third of the distal tibia or fibula. (A 扁平足)3. SUPINATION (旋後; 高弓足)16不同的足型(Identifying Foot Type)扁平足(旋前足)扁平足(旋前足扁平足(旋前足)高弓足(旋後足) 高弓足(旋後足)正常足正常足扁平足(旋前足)versus高弓足(旋後足)內旋(Internal Rotation) 外旋(external Rotation)NeutralNo pronation / supination at the STJCopyright Vasyli 2005Fig A Fig B Fig C19Pronat
4、ion Eversion Frontal AbductionTransverse Dorsiflexion SagittalCopyright Vasyli 2005L E N G T H E N I N G 20Inversion FrontalSupinationAdduction Transverse Plantarflexion SagittalCopyright Vasyli 2005S H O R T E N I N G Post Tib.21Closed Chain Pronation (站立旋前動作鏈) Hip: Flex, Add, IR Knee: Flex, Valgus
5、 Lower Leg: IR Talus: PF, Add Calcaneus: EV Midtarsal: DF/AB, IV 1st Ray: DF, IV (Loss of MLA) Hallux: Loss of DF 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 Ex
6、cess Compensatory Pronation过多的代偿旋前Nature v Civilisation 4 23 423 1 2005 Vasyli InternationalLEFT FOOT 1. Calcaneal eversion 2. Decreased MLA 3 Increased medial loading 4. Internal Tibial rotation 1 RIGHT FOOT 1. Calcaneal inversion 2. Increased MLA 3. Decreased medial loading 4. External Tibial rota
7、tionEXCESS PRONATION 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 its “normal” range of motion.25足弓塌陷的可能后果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。27Plantar Fascitis28Achill
8、es TendinitisFemoral PositioningRight 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
9、against the anterior part of the acetabulum.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Pelvic RotationThe cervical spine counterbalances the lumbar side bending by side bending right which places the left rectus capitis major posterior muscle on a stretch. The lumbar spine compensa
10、tes by side bending left which places the right quadratus laborum muscle on a stretch.The pelvis tilts downward to the right. A functionally short right leg.Excessive pronation pattern of right left pulls both innominates anteriorly.Functional LLD Unilateral excessive foot pronation =functional shor
11、tening of limb(Sanner et al., 1981)Link to Sciatic EntrapmentAnterior rotation of the innominate, if severe enough, can compress the Sciatic Nerve against the greater sciatic notch. Sway Back Bilateral foot pronation both femoral heads are positioned posteriorly which dumps the pelvic contents forwa
12、rd increased lumbar lordosis, lumbosacral angle and jamming of the L4-5 and L5-S1 facets. (sway back)Arch Support 36Foot Orthosis (鞋墊或足部矯形器) Orthosis: 從希臘字”ortho” 衍生而來.Ortho: make straight (變直)作用：prevent deformities、enhance walking、promote osteogensis、alleviate pain、strengthen limb and spine.Foot or
13、thosis is defined as the external device to foot to improve or correct flexible deformity or prevent progressing of fixed deformity. To restore the normal function of foot.Orthotic Management意外的發現旋前(Pronation) versus 旋後(Supination)外翻 外展 背屈 內翻 內收 趾屈Single Plane MovementSagittal Plane: flexion/extensi
14、onFrontal Plane: Inversion/ EversionTransverse Plane: Abduction/ Adduction Ankle Joint AxisTalus and Ankle Joint:Talus is wedge shaped with wider portion anterior, no varus-valgus movement will be possible with ankle held dorsiflexion, unless malleoli or tibiofibular ligaments are damaged. Osteokine
15、maticsAnkle is a modified sellar synovial joint with one degree of freedom: plantaflexion and dorsiflexion.Ankle Dorsiflexion AssessmentMaintain knee extended and STJ in slight supination Need at least 10 DF (note leg to lateral heel)Tightness is common! Check again at 90 degrees knee flexion45Ankle
16、 Equinus ClassificationOsseous: a hard end feel. Soft Tissue: a gastrocnemius equinus. a gastrocnemius-soleus equinus.46Heel Drop ExerciseTalus Traction ManipulationThe problem joint is distracted and then let go to reposition normally. The PT stands in line with the leg by the foot. The PTs hands a
17、re wrapped around the instep of the foot so that the little or ring finger of one hand is over the neck of talusThe manipulation is effected by a sharp pull distally in line with the tibia, causing the talus to distract from the mortise. Traction Manipulation勿over-dorsiflexionMobilization for Ankle
18、DorsiflexionMobilization for Ankle Plantar-flexion與charpots line 平行MWM for Ankle Dorsiflexion(Talus)Start Near End-rangeFibula is the keyCommon posterior subluxed fibular head with tibial external torsion and inversion ankle sprains. Very common to have proximal posterior tibiofibular restriction an
19、d an anterior subluxed distal tibiofibular restriction which responds well to manual therapy. Distal Tibiofibular Joint The ankle is a hinge joint formed superiorly by the distal tibia and fibula and inferiorly by the dome of the talus. During dorsiflexion, the wider portion of the talar dome must g
20、lide posteriorly. fibula to translate. (cranially and laterally), widening the mortise and permitting the talus its required range of motion.MWM for Ankle Dorsiflexion(Distal Fibula)Manipulation of Proximal Fibula for Ankle DorsiflexionSubtalar Joint Anatomy The superior surface of the calcaneus is
21、concave anteriorly while posteriorly it is convex. As both surfaces have to move simultaneously. This joint has only one degree of freedom, inversion and eversion. The joint is essentially two joints in one. Subtalar Joint Axis The axis of the subtalar joint lies at approximately 42 in the sagittal
22、plane and at approximately 16 in the horizontal plane.mages/anatomy/hfang3.gif58Subtalar Joint PRONATION EVERSION ABDUCTION DORSIFLEXION SUPINATION INVERSION ADDUCTION PLANTARFLEXION Ankle Joint AxisTalocrural JointPRONATIONDORSIFLEXIONABDUCTION EVERSIONSUPINATIONPLANTARFLEXIONADDUCTION INVERSIONANK
23、LESAGITTALFRONTALTRANSVERSESubtalar Joint 16 off the Sagittal Plane42 off the Transverse PlaneSubtalar Joint AxisSubtalar Joint AxisPRONATIONEVERSIONABDUCTION DORSIFL IONSUPINATIONINVERSIONADDUCTIONPLANTARFLEXIONSUBTALAR SAGITTALFRONTALTRANSVERSELongitudinalMidtarsal Joint Axis9 off the SagittalPlan
24、e15 off the Transverse Plane59Subtalar Joint Neutral Assessment Assess rearfoot alignment (posterior calcaneus to lower leg) Assess forefoot to rearfoot (plane of metatarsals 1-5 relative to posterior calcaneus) If first ray is PF, ascertain plane of 2-5. Placing straight plane object (tongue blade,
25、 etc) improves visualization and reliability.Subtalar Joint ROM:eversion available Evert (and abduct) calcaneus to check pronatory range Invert (and adduct) calcaneus to assess supinatory range Normal: 30 degrees total, 20 degrees IV and 10 degrees EV If triplane axis is followed,typically present with greater range 2:1 ratio is not reliably present Lateral ankle injury increases inversion range
