Professional Documents
Culture Documents
C o n t e n t s
3.1 Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . 50 by Justin Wernick, DPM 3.2 Common Orthopedic Pathologies of the Foot and Ankle. . . . . . . . . . . . . . . . . . . . . . . 107 by Steve Levitz, DPM and Justin Wernick, DPM 3.3 Neuromuscular Disease and Electrodiagnosis 119 by Ellen Sobel, DPM 3.4 Orthotics and Prosthetics . . . . . . . . . . . . . . 139 by Ellen Sobel, DPM and Lauren Jones, DPM 3.5 Pathological Gait . . . . . . . . . . . . . . . . . . . . . 161 by Aaron Glockenberg, DPM 3.6 Pathomechanics . . . . . . . . . . . . . . . . . . . . . 169 by Justin Wernick, DPM 3.7 Physical Medicine . . . . . . . . . . . . . . . . . . . . 205 by Loretta Logan, DPM and Carl Harris, DPM 3.8 Sports Medicine . . . . . . . . . . . . . . . . . . . . . 225 by Josh White, DPM and Lauren Jones, DPM
Orthopedics
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3.1
Biomechanics
Introduction
Biomechanics is the study of the structure and function of the biological systems by means of the methods of mechanics. ASB,1975
Body Planes
Dorsiflexion
A movement on the sagittal plane where the distal part of the foot or segments of the foot moves toward the anterior of the leg.
Position
Dorsiflexed Calcaneous
Plantarflexion
A movement on the sagittal plane where the distal part of the foot or segments of the foot moves away from the anterior of the leg.
Position
Plantarflexed Equinus
Orthopedics | Biomechanics
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Orthopedics | Biomechanics
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Abduction
A movement on the transverse plane where the distal part of the foot or segments of the foot moves away from the midline of the body.
Adduction
A movement on the transverse plane where the distal part of the foot or segments of the foot moves towards the
Position
Abducted
Eversion
A movement on the frontal plane where the plantar surface of the foot or segments of the foot faces away from the midline of the body.
Position
Everted Valgus
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Inversion
A movement on the frontal plane where the plantar surface of the foot or segments of the foot faces toward the midline of the body.
Position
Inverted Varus
Functional Definitions
Upper segment => Talus and the leg Lower segment => Calcaneus and the foot Rearfoot => Talus and the calcaneus Forefoot => Distal to the MT joint
Hypermobility
Hypermobility implies instability and is defined as movement of a segment or part that should be fixed and stable when stress is applied.
Abnormal Compensation
An abnormal change of structure, position, or function of one part in an attempt by the body to neutralize the effects of a deviation of structure, position, or function of another part. The results are pathological.
Daily Stress
Walking and standing on a hard, unforgiving surface + Number of steps taken each day + Average body weight = The amount of force the feet and body are exposed to each day Average number of steps taken each day(10,000) X Average body weight (150 lbs) = The amount of force the feet and body are exposed to each day (1,500,000 lbs!)
Axis
The axis is an imaginary line passing through the center of a body about which a rotating body turns; synonymous with an axle.
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Axis of Motion
The hinge around which motion takes place. The motion is always perpendicular to the plane or planes in which the axis is placed.
Triplane Motion
A motion-taking place, consisting of three components where the axis of the motion makes an angle to all three-body planes.
Pronatory/Supinatory Axes
A pronatory/supinatory axis is directed from posterior, lateral, inferior to dorsal, medial, anterior.
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Triplane Motion
Components of the motion
Planal Dominance
The determination of a motion at a given joint based upon the orientation of the axis. Planal dominance of the individual foot is important to the evaluation of the function of the foot. The direction in which an individual foot can compensate is important. The primary plane of compensation and the amount of available range are important considerations when evaluating foot function. Green,D.,Carol,A., Planal Dominance, JAPA,Vol.74, #2
Even in our everyday attempts to control the variety of foot types seen in our offices, planal dominance can play a major part in our success. Green,D.,Carol,A., Planal Dominance, JAPA,Vol.74, #2
General Rules
After a thorough assessment of the patient, determine on which body plane(s) the pathologic influence is taking place Then determine which joints the pathological influence will select to compensate for the influence. It will be the joints with the largest component in that body plane Determine if there is an adequate range of motion in the joint(s) selected to fully compensate for the influence
Orthopedics | Biomechanics
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Orthopedics | Biomechanics
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Forefoot/Rearfoot Relationship
The forefoot/rearfoot relationship is represented by the transverse plane of the lesser metatarsal heads (2-4) being perpendicular to the calcaneal bisection when the subtalar joint is in neutral and the midtarsal joint is maximally pronated.
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Orthopedics | Biomechanics
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Subtalar Joint
A pronatory/supinatory axis whose motion will appear clinically as: Eversion/abduction of the rearfoot with pronation Inversion/adduction of the rearfoot with supination
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Rotation at the subtalar joint converts transverse plane motion to frontal plane motion via a mitered hinge
Effects of Friction
Friction enhances sagittal plane walking by converting internal and external rotation at the hip to pronation and supination at the subtalar joint.
Subtalar Joint
On closed chain, the motion will appear clinically as: Eversion of the calcaneus with pronation Inversion of the calcaneus with supination
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General Effects
The average range of motion of the subtalar joint has been found to be approximately 25 - 30. The ratio of supination to pronation is usually 2:1 but may be 4:1.
Pronation
Supination
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Neutral Position
Definitions
A position of a joint from which maximum function may occur in any of the permissible directions. A position where the joint is neither supinated nor pronated and the body of the talus is in line with the body of the calcaneus.
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A pronatory / supinatory axis whose motion will appear clinically as: Dorsiflexion and abduction with pronation Plantarflexion and adduction with supination
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On closed chain, the motion will appear clinically as: Pronation of the rearfoot with supination of the forefoot Supination of the rearfoot with pronation of the forefoot
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Range of motion
The average range of Motion of the longitudinal MT Jt is 22. Pronation of the subtalar joint requires 4 - 6 of complimentary supination of the forefoot. There is only supination available when the subtalar joint is neutral.
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An increase in internal rotation of the leg will increase the sagittal plane component.
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Components
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Range of Motion
The 1st ray has a range of motion of 5 mm dorsally and 5 mm plantarly for a total range of 10 mm.
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Axes of Motion
IRolling motion II, IIISliding motion associated with 1st ray plantarflexion IVCompression
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As the 1st ray plantarflexes, it slides plantarly in relationship to the base of the proximal phalanx.
Once the heel has lifted maximally, the 1st ray will fully compress against the base of the proximal phalanx.
The range of motion available at the 1st MP joint weight bearing is approximately 20. This is consistent with the rolling segment of the motion.
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Orthopedics | Biomechanics
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Elevatus of the 1st Ray Secondary to Pronation of the Rear Foot at Propulsion
Compensations for sagittal plane blockade of the 1st MP joint Intrinsic compensations Dorsiflexion of the IP joint with medial roll-off Inverted forefoot at propulsion. (Low gear) Abducted gait S.A.R.P. (Secondary Active Retrograde Pronation) Hallux abducto-valgus deformity Extrinsic compensations
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Orthopedics | Biomechanics
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Kinetic Wedge
Problem: Functional Hallux Limitus (FHL)
Dorsiflexion of the 1st ray at propulsion Compensation causes foot symptoms Compensation causes postural symptoms
Summary
The 1st ray is required to plantarflex and evert during the heel lift stage of walking Motion at the 1st metatarso-phalangeal joint consists of rolling, sliding with compression at the end range Factors that cause an elevatus of the 1st ray to occur will block motion and create a functional hallux limitus Intrinsic and extrinsic compensations for this sagittal plane blockade will occur
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On closed chain, the motion will appear clinically as: Dorsiflexion/abduction of the 5th ray Plantarflexion/adduction of the 5th ray
GAIT
GENERAL CONCEPTS
2 periods of double support (25%) 2 periods of single support (75%) 0 - heel strike 7% - footflat 12% toe-off of opposite limb 15% full heel eversion occurs 34% heel rise 50% heel strike of opposite limb 62% toe-off (reswing) Heel rise occurring before 34% = Gastroc spasticity Footflat not occurring by 7% = Gastroc spasticity Heel rise occurring later than 34% = Gastroc weakness
GAIT CYCLE
STANCE PHASE
CONTACT (0-15%) HEEL STRIKE TO FOOTFLAT CALCANEUS everts (passively) maximum to 15% Entire lower extremity internally rotates ANKLE JOINT plantar flexes to ~20% KNEE flexes 15-20o HIP flexes QUADRICEP (L2,3,4) contract eccentrically to stabilize knee and prevent buckling GLUTEUS MAXIMUS acts as break preventing too much truck flexion ANTERIOR LEG MUSCLES (L4) contract eccentrical slowing down ankle joint plantarflexion MIDSTANCE (15-34%) FOOTFLAT TO HEEL OFF CALCANEUS inverts EXTERNAL ROTATION initiated by contralateral swing limb ANKLE JOINT dorsiflexes to 20 KNEE extends HIP extends GLUTEUS MEDIUS (L5) holds pelvis down on stance side ERECTOR SPINAE and HIP ADDUCTORS contract to hold swing leg up CALF MUSCLES eccentrically contract to control ankle joint dorsiflexion
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PROPULSION (34-60%) HEEL-OFF TO TOE-OFF CALCANEUS inverts EXTERNAL ROTATION of stance limb continues ANKLE JOINT plantarflexes ~20 KNEE flexes to 40 HIP flexes CALF MUSCLES (S1, S2) concentrically plantarflex calf
SWING PHASE
INITIAL SWING (ACCELERATION) CALCANEUS everts (STJ pronates) Internal rotation of the leg ANKLE JOINT dorsiflexes to clear ground KNEE flexes to 60 HIP flexes ILEOPSOAS initiates swing phase of gait ANKLE DORSIFLEXORS concentrically contract for foot to clear ground MIDSWING Swing leg is adjacent to weight-bearing leg Internal rotation of leg continues KNEE flexes 60 HIP flexes TERMINAL SWING (DECELERATION) CALCANEUS inverts INTERNAL ROTATION of leg continues ANKLE JOINT remains dorsiflexed to 90 KNEE extends HIP extends GLUTEUS MAXIMUS slows down swinging limb HAMSTRINGS control hip flexion and also slow down swinging leg QUADRICEPS control knee extension