足踝临床生物力学治疗与评估-蔡永裕

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NorthwesternUniversity骨科碩士澳洲Vasylimedical足踝醫療顧問前足中足後足鼎足而三MedialSideLateralSide:Functionally,allthearticulationsactasonestructure.1.Chopart’sjoint(Transversetarsal):betweenposteriorsegment(talusandcalcaneus)andmiddlesegment(navicularandcuboid)2.Lisfranc’sjoint(tarsometatarsal):betweenmiddleandanteriorsegment.Ottawa-BuffaloAnkleguidelines:X-rayornot•Cannotbearweightforfoursteps(twostepsoneachfoot)•Havetendernessoverthedistal6cmofthemidthirdofthedistaltibiaorfibula.(A&B)•Havepointtendernessoverthebaseofthe5thmetatarsus(C).•Havepointtendernessoverthenavicular(D).3Arches•MedialLongitudinalArch:–absorbsthemajorityoftheshockofimpact–calcaneus,talus,navicular,cuneiforms,andthefirst(3)metatarsals.•LateralLongitudinalArch:–calcaneus,cuboid,andthefourthandfifthmetatarsals.•TransverseArch:–cuneiforms,thecuboid,andthefivemetatarsalbases.內側縱弓MedialLongitudinalArch•Formationofahealthymediallongitudinalarchrequirestheformationofawell-developedsustentaculumtali,ahealthytibialisposteriortendon,anadequatedeltoidligament,anonconstrictedAchillestendon,andaproperlyplacedinferiorcalcaneonavicularligament.10MedialLongitudinalArchDevelopment研究指出MedialLongitudinalArch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)。11ArchDevelopment•RaoandJoseph:(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。•RobbinsandHanna:(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sustentaculumtali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sustentaculumtali骨化完全)足部過度旋前，可以模制sustentaculumtali，使其不再向下的形成斜坡，支持距骨。NeutralSupinationPronationTri–PlaneMotionINVERSIONFADDUCTIONTPLANTARFLEXIONSEVERSIONFABDUCTIONTDORSIFLEXIONSEXTERNALROTATIONTINTERNALROTATIONT13IsaacNewton(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。•Inventedcalculusatage24•PhilosophiaeNaturalisPrincipiaMathematica(1686)其中载有他的现在著名的三大运动定律–惯性，加速度，作用力和反作用力万有引力定律14地面反作用力反作用力身體重量足部的特徵(ProfilesoftheFoot)•３種型態：1.NEUTRAL(正中)2.PRONATION(旋前;扁平足)3.SUPINATION(旋後;高弓足)16不同的足型(IdentifyingFootType)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(InternalRotation)外旋(externalRotation)NeutralNopronation/supinationattheSTJCopyrightVasyli©2005FigAFigBFigC19PronationEversionFrontalAbductionTransverseDorsiflexionSagittalCopyrightVasyli©2005LENGTHENING20InversionFrontalSupinationAdductionTransversePlantarflexionSagittalCopyrightVasyli©2005SHORTENINGPostTib.21ClosedChainPronation(站立旋前動作鏈)Hip:Flex,Add,IRKnee:Flex,ValgusLowerLeg:IRTalus:PF,AddCalcaneus:EVMidtarsal:DF/AB,IV1stRay:DF,IV(LossofMLA)Hallux:LossofDFClosedChainSupination(站立旋後動作鏈)Hip:Ext,Abd,ERKnee:Ext,VarusLowerLeg:ERTalus:DF,AbdCalcaneus:IVMidtarsal:PF/AD,EV1stRay:PF,EV(IncreasedMLA)Hallux:EnhancedDFExcessCompensatoryPronation过多的代偿旋前NaturevCivilisation4234231©2005VasyliInternationalLEFTFOOT1.Calcanealeversion2.DecreasedMLA3Increasedmedialloading4.InternalTibialrotation1RIGHTFOOT1.Calcanealinversion2.IncreasedMLA3.Decreasedmedialloading4.ExternalTibialrotationEXCESSPRONATIONTherefore,itis“normal”thatforeverystepwetakeonahardflatUNNATURALsurfaceforthefoottoExcessivelyPronate,I.E.gobeyondit’s“normal”rangeofmotion.25足弓塌陷的可能后果RoyalWhitman(1857-1946)哈佛大学毕业和纽约市的著名骨科医生•對“Weakfoot的描述非常接近我们目前描述的扁平足。27PlantarFascitis28AchillesTendinitisFemoralPositioningRightLE:pronatedfootinternallyrotatestheleftlowerextremity,thefemoralneckalsointernallyrotatespushesthefemoralheadposteriorlyagainstthebackoftheacetabulumLeftLE:footsupination,externallyrotatesthefemoralneckThefemoralheadtopushagainsttheanteriorpartoftheacetabulum.右邊股骨頭(rightfemoralhead)往後推，而左邊股骨頭往前推擠髖臼(acetebulum)造成骨盆往左旋轉PelvicRotationThecervicalspinecounterbalancesthelumbarsidebendingbysidebendingrightwhichplacestheleftrectuscapitismajorposteriormuscleonastretch.Thelumbarspinecompensatesbysidebendingleftwhichplacestherightquadratuslaborummuscleonastretch.Thepelvistiltsdownwardtotheright.Afunctionallyshortrightleg.Excessivepronationpatternofrightleftpullsbothinnominatesanteriorly.FunctionalLLD•Unilateralexcessivefootpronation=functionalshorteningoflimb(Sanneretal.,1981)LinktoSciaticEntrapmentAnteriorrotationoftheinnominate,ifsevereenough,cancompresstheSciaticNerveagainstthegreatersciaticnotch.SwayBack•Bilateralfootpronationbothfemoralheadsarepositionedposteriorlywhich‘dumps’thepelviccontentsforwardincreasedlumbarlordosis,lumbosacralangleandjammingoftheL4-5andL5-S1facets.(swayback)ArchSupport36FootOrthosis(鞋墊或足部矯形器)•Orthosis:從希臘字”ortho”衍生而來.–Ortho:makestraight(變直)–作用：preventdeformities、enhancewalking、promoteosteogensis、alleviatepain、strengthenlimbandspine.–Footorthosisisdefinedastheexternaldevice•tofoottoimproveorcorrectflexibledeformityorpreventprogressingoffixeddeformity.•Torestorethenormalfunctionoffoot.OrthoticManagement意外的發現旋前(Pronation)versus旋後(Supination)外翻外展背屈內翻內收趾屈SinglePlaneMovementSagittalPlane:flexion/extensionFrontalPlane:Inversion/EversionTransversePlane:Abduction/AdductionAnkleJointAxisTalusandAnkleJoint:Talusiswedgeshapedwithwiderportionanterior,novarus-valgusmovementwillbepossiblewit