POSTUROLOGIE.ppsx

Introduction to clinical posturology

CharbelKortbawiDO Osteopathic Medicine

Chapter One Balance & Posture

Chapter One Balance & Posture I. Definitions

Definitions 

Posture

What is Posture? 

“The position of the body at a given point in time.” (Starkey)



“A set of muscle contractions that place the body in the necessary location from which a movement is performed.” (Enoka)

What is Posture? 

Purpose : ◦ to counteract gravity, which pulls the body toward the ground ◦ Stabilize the body when initiating, executing and achieving a movement ◦ Maintain the horizontal axe of vision

Definitions 

Balance

Balance Or Stability? 

A state of equilibrium characterized by cancellation of all forces by equal opposing forces



Balance requires keeping the “Center of Mass” (COM) over the “Base of Support” (BOS) during static and dynamic situations  If this relationship isn’t maintained then the system will be unbalanced

Base of Support (unipedal)

Base of Support (bipedal)

Base of Support 

“ A person in an upright standing posture is in equilibrium as long as the line action of the weight remains within the boundaries of the base of support and the person is stable as long as the musculoskeletal system can accommodate perturbation and return to an equilibrium position “ Latash et al. 2003

Base of Support Static

Dynamic

x TM-L

TM-R

x H-H

Walking

x- Vertical projection of COG

Base of Support 

Transition from static to dynamic ◦ Heel-to-heel distance will decrease  Feet come together toward midline

◦ Toe-to-midline distance will decrease ◦ Overall effect - BOS narrows

Base of suport 

Effect of a narrowed BOS : ◦ Chances of COG falling within BOS decrease  Subject becomes less (un-) balanced

◦ COG moves forward of BOS - precursor event to walking  Foot will be advanced to extend the dynamic BOS

Limits of Stability

Inverted pendulum !!

Limits of Stability

Relationship - Balance & Posture 

Postural alignment (and the changes/adjustments made due to perturbations) is the way balance is maintained



Maintaining the COG within the BOS ◦ If this relationship isn’t maintained then a system will be unbalanced

Strategies to Maintain/Restore Balance Ankle strategy  Hip strategy  Stepping strategy 



Strategies are automatic and occur 85 to 90 msec after the perception of instability is realized

Strategies to Maintain/Restore Balance 

Ankle strategy (young subjects) ◦ Used when perturbation is  Slow  Low amplitude

◦ Contact surface firm, wide and longer than foot ◦ Muscles recruited distal-to-proximal ◦ Head movements in-phase with hips

Strategies to Maintain/Restore Balance


Hip Strategy (elderly) ◦ Used when perturbation is fast or large amplitude ◦ Surface is unstable or shorter than feet ◦ Muscles recruited proximal-to-distal ◦ Head movement out-of-phase with hips



Stepping Strategy ◦ Used to prevent a fall ◦ Used when perturbations are fast or large amplitude -orwhen other strategies fail ◦ BOS moves to “catch up with” COG


Definitions 

Postural control

Postural control Controlling the body’s position in space for the dual purposes of stability and orientation” (Shumway-Cook and Woollacott 1995) 

Postural control allows us: 

Support the head and body against gravity and other external forces.



Provide a reference frame and stability to selectively move our eyes, head or limbs.



Move from one position to another.



Carry out cognitive tasks while moving (dual tasks)

Postural control 

The postural control system operates by controlling the connection between the sensory /musculoskeletal system and CNS



Each sense provides the CNS with specific information about position and motion of the body

Postural control components

Model Components Musculoskeletal System ROM of joints  Strength/power  Sensation 

◦ Pain ◦ Reflexive inhibition 

Muscle tone ◦ Hypertonia (spasticity) ◦ Hypotonia

Model Components Goal/Task Orientation What is the nature of the activity or task?  What are the goals or objectives? 

Model Components Central Set Past experience may have created “motor programs”  CNS may select a motor program to fine-tune a motor experience 

Model Components Environmental Organization 

Nature of contact surface ◦ Texture ◦ Moving or stationary?



Nature of the “surrounds” ◦ Regulatory features of the environment

Model Components Motor Coordination 

Movement strategies ◦ Based on repertoire of existing motor programs

Feedback & feedforward control  Adjustment/tuning of strategies 

Sensory organisation 

Balance/postural control via three systems ◦ Visual system ◦ Vestibular system ◦ Somatosensory system ◦ Stomatognathic system ???

Posturology ??? 

Posturology : the discipline studying the relation

between

body

posture

and

muscoloskeletal disorders and chronic pain.

Chapter 2 Physiology of postural control

Chapter 2 Physiology of postural control I.

The somatosensory system

Somatosensory System 



The somatosensory system transmits sensations of the body to the brain 3 Parts

Somatosensory Cortex

Somatosensory or Ascending Pathways Somatosensory Receptors 40

Physiology Postural Control & Stability

Somatosensory System 

Somatosensory receptors: extero and intero receptors



Somatosensory pathways: also called the ascending tracts



Somatosensory cortex: divided into ◦ Primary cortex ◦ Secondary cortex ◦ Association cortex

Somatosensory Receptors Classification based on: 1. Locationa. interoceptors b.Exteroceptors a. mecanoreceptors

2. Type of stimulus detectedb. thermoreceptors c. photoreceptors d. nociceptors

3. Structural complexity b. complex

a. simple

Exteroceptors 

Receptors located on/near the surface of the skin and are sensitive to stimuli occurring outside or on the surface of the skin.



Ex: touch, pain,temperature, as well as those for vision,

hearing,

smell,

and

taste.

Interoceptors 

Interoceptors respond to stimuli occurring in the body from visceral organs,blood vessels, joints

and

muscles.

Proprioceptors 

Proprioceptors respond to stimuli occurring in skeletal muscles, tendons, ligaments, and joints. These receptors collect information concerning body position and the physical conditions

of

these

locations.

Chapter 2 Physiology of postural control I. II.

The somatosensory system The visual system

The Visual System

Martin J.P, 1967

The Visual System

The visual system

The Visual System



Exteroception ◦ Retinal vision



Proprioception ◦ Extraocular muscles

The retinal vision 

Foveal vision ◦Provides specific information to allow us to achieve action goals, e.g. For reaching and grasping an object – specific characteristic info, e.g. size, shape, required to prepare, move, and grasp object For walking on a pathway – specific pathway info needed to stay on the pathway

The retinal vision 

Peripheral vision ◦Detects info beyond the central vision limits ◦Provides info about the environmental context and the moving limb(s) ◦Gives a general impression of the situation

The extraocular muscles

The extraocular muscles physiology

Medial rectus (MR)— * moves the eye inward, toward the nose (adduction) lateral rectus (LR)— * moves the eye outward, away from the nose (abduction) superior rectus (SR)— * primarily moves the eye upward (elevation) inferior rectus (IR)—

* primarily moves the eye downward (depression) * secondarily rotates the top of the eye away from the nose (extorsio superior oblique (SO)— * primarily rotates the top of the eye toward the nose (intorsion) * secondarily moves the eye downward (depression) inferior oblique (IO)—

* primarily rotates the top of the eye away from the nose (extorsion) * secondarily moves the eye upward (elevation)

The extraocular muscles

The extraocular muscles physiology 

Constantly inform the brain to the position of the eyeball  Cervico ocular reflex : stabilize the image on the retina.

Chapter 2 Physiology of postural control I. II. III.

The somatosensory system The visual system The vestibular system

The vestibular system

The vestibular system 

Provides information: ◦ Head linear acceleration ◦ Angular acceleration (Head rotations) ◦ Head position (antigravity muscles) ??


Maintain balance (posture & equilibrium) by monitoring motion of the head



Stabilize the eyes relative to the environment


Important: ◦ In quiet standing posture, the vestibular system don’t interfere with posture stability and balance.  No acceleration = no vestibule signal  No eye movement = no vestibule signal (spatial orientation)

Chapter 2 Physiology of postural control I. II. III. IV.

The The The The

somatosensory system visual system vestibular system mechanoreceptors of the foot

Sensory receptors of the foot

Sensory receptors of the foot 

Proprioception ◦ Muscles spindles ◦ Golgi receptor organs ◦ Joint receptors



Exteroception +++ ◦ Cutaneous Mechanoreceptor (the plantar sole)

Proprioceptors 

Muscle spindle: ◦ Functions as a stretch receptor

monitoring the length of the muscle in which it is embedded; its greatest density is near the belly

of

ballistic

the

muscle;

stretching

rapid,

stimulates

the muscle spindle causing an involuntary contraction of the muscle being stretched

Proprioceptors 

◦

Golgi receptor organs A small sensory receptor, located at the junction between a muscle and tendon, that monitors tension. The organ is activated by muscular

contractions

that

stretch

the

tendons. The result in an inhibition of alpha motor, causing the contracting muscle to relax, thereby protecting the muscle and connective tissue from excessive loading.

Proprioceptors 

Joint receptors ◦ Joint

kinesthetic

receptors

located within and around the articular capsules of synovial joints ◦ Free nerve endings and type II cutaneous

mechanoreceptors

in

capsules

joint

detect

pressure ◦ lamellated corpuscles outside articular

capsules

detect

acceleration and deceleration of joint movement

The mechanoreceptors 



Definition: A mechanoreceptor is sensory receptorthat responds to mechanical pressure or distortion 4 main types: ◦ Meissner’s corpuscles: detects changes in texture (vibrations around 50 Hz); adapts rapidly ◦ Pacinian corpuscles: detects rapid vibrations (about

200-300 Hz) ◦ Merkel’s discs: detects sustained touch and pressure. ◦ Ruffini corpuscles: detects tension deep in the skin

The mechanoreceptors

Mechanoreceptors of the foot

Responses of four types of mechanoreceptors to normal indentation of the skin


Distribution of cutaneous mechanoreceptors in the foot


The generated potential originates from unmyelinated nerve terminal

Mechanoreceptors of the foot The plantar regions were stimulated by pairs of surface electrodes (•): delivery of rectangular pulses (0.5 ms duration, 100 Hz) at nonpainful intensity (1.2 × perception threshold). Individual final positions of the CoP after 2.5 s of stimulation for 5 subjects are shown (○); their means are represented (□). Vectors show that body tilts are contralaterally oriented with respect to the stimulation sites.


Action potential in an afferent fiber from a mechanoreceptor of a single sensory unit increase in frequency as branches of the afferent neuron are stimulated by pressure of increasing magnitude

Mechanoreceptors of the foot 

The cutaneous mechanoreceptors of the foot: ◦ Essentials for postural control +++ ◦ constantly

Inform

the

CNS

that

compares

information from both feet and detects floor irregularity.

The Stomatognathic system

A dynamic biomechanical musculoskeletal system

The Stomatognathic system 

Stomatognathic = mastication system



TMJ + teeth + related close structure

TM Joint Anatomy 

The mandible


The mandible


The mandible ◦ ◦ ◦ ◦ ◦

Odd, median and symmetric bone 3 parts: horizontal body and 2 vertical branches Mobile part of the skull The body supports the inferior dental arch The branches divided in 2 parts:  Coronoid process  Condylar process

TMJ Anatomy

TMJ Anatomy Ginglymoarthrodial joint



◦

Hinge and Translation



Unstable Joint



Intra-articular disc separates the joint in a superior and inferior components biomechanically different 4 anatomical parts:



◦

The condyle

◦

glenoidfossa of the temporal bone

◦

Articular disc

◦

Articular capsule

TMJ Anatomy

TMJ Anatomy Ligaments : 1-collateral(discal) 2-capsular 3-sphenomandibular 4-stylomandibular 

Accessory ligament limit border movements of the mandible.



Fibrous capsule and TM ligament limit of extreme lateral movements in wide opening of mandible

TMJ anatomy 

Ligaments

TMJ Anatomy 

Articular disc: ◦ Biconcave oval structure interposed between the condyle and the temporal bone ◦ 1 mm in the middle and 2-3 mm at periphery ◦ Dense collagenous connective tissue ◦ Centre area is a vascular, hyaline and devoid of nerve

TMJ Anatomy 

4 important muscles ◦ Masseter muscle ◦ Temporalis muscle ◦ Medial pterygoid muscle ◦ Lateral pterygoid muscle

TMJ Anatomy 

Masseter muscle ◦ Superficial layer: ◦ O : lower border of malar bone, Zygomatic arch &zygomatic process of maxilla ◦ D : Downward Backward

and

◦ I : Angle of mandible and inferior half of the lateral side of mandible

TMJ Anatomy 

Masseter muscle ◦ Deep layer: ◦ O : Internal surface of zygomatic arch ◦ D : Downward (vertical) ◦ I : Ramus of mandible and base of coronoid process ◦ F: elevation of mandible

TMJ Anatomy 

Temporalis muscle ◦ O: Bone of temporal fossa& temporal fascia ◦ I: coronoid process of mandible & anterior margin ramus of mandible almost at the last molar tooth ◦ F: elevation & retraction of mandible

TMJ Anatomy 

Medial pterygoid ◦ O: Deep head- lateral plate of pterygoid process and pyramidal process of palatine bone; superficial head- tuberosity and pyramidal process of maxilla ◦ I: Medial surface of mandible near Angle ◦ F: Elevation and 'side-to-side' movements of the mandible

TMJ Anatomy 

Lateral pterygoid ◦ O: ◦ Upperhead-roof infratemporalfossa;

of

◦ lower head-lateral surface of lateral plate of the pterygoid process ◦ I: Capsule of temporomandibular joint in the region of attachment to the articular disc and to the pterygoid fovea on the neck of mandible ◦ F: Protrusion and 'side-to-side' movements of the mandible

Anatomy of the mandible 

Non Masticatory Muscles

◦ Digastric muscle ◦ Mylohyoid muscle ◦ Geniohyoid muscle ◦ Orbicularis Oris

Physiology of the TMJ 

Essentiel movements: ◦ Rotations: inferior compartment (hinge) ◦ Translation (protrusion): superior compartment (glide) ◦ First 20mm of motion is rotation. The mandible and meniscus move anteriorly together beneath the articular eminence while opening or closing ◦ Second motion is translation, which slides the jaw further forward or from side to side



Combined movements: ◦ Opening andclosingthe mouth ◦ Lateral transaltion movement (side to side)


Combined movements: ◦ Opening and closing the mouth ◦ Lateral transaltion movement (side to side)

Physiology of the TMJ

Hinge + translation = ginglymoarthrodial


Around a horizontal axe (hinge axe)



Translation movement or protrusion



mandibular lateral translation movement

Dental Occlusion 

Dental occlusion is the way in which your upper and lower teeth come into contact with each other. Whether this is at rest or while your chewing, dental occlusion is all about how your teeth touch each other and whether their alignment is healthy or not.

Dental Quandrant

Relation between SS and posture 

Disturber of the postural system



Tension in the SS contribute to impaired neural control of posture via the trigeminal system



Role of the myofascial system

TMJ Dysfunction

Occlusion disorders

Clenching (bruxism)

Jaw muscles & TMJ dysfunctions

Antecedent of Trauma

TMJ Dysfunction 

Bruxism: Involuntarily or unconsciously clenching or grinding the teeth, typically during sleep

How SS dysfunction affects posture ? Disorder of the SS

Adaptive postural reflexes

Nociceptive reaction

Adaptive postural reflexes 

3 Important reflexes: ◦ Manducatory postural reflex originated from the TMJ ◦ Oculomotor postural reflex originated from the TMJ ◦ Spinal postural reflex originated from the TMJ.













The reticular formation consists of more than 100 small neural networks, with varied functions including the following: 1. Somatic motor control - Some motor neurons send their axons to the reticular formation nuclei, giving rise to the reticulospinal tracts of the spinal cord. These tracts function in maintaining tone, balance, and posture--especially during body movements. The reticular formation also relays eye and ear signals to the cerebellum so that the cerebellum can integrate visual, auditory, and vestibular stimuli in motor coordination. Other motor nuclei include gaze centers, which enable the eyes to track and fixate objects, and central pattern generators, which produce rhythmic signals to the muscles of breathing and swallowing. 2. Cardiovascular control - The reticular formation includes the cardiac and vasomotor centers of the medulla oblongata . 3. Pain modulation - The reticular formation is one means by which pain signals from the lower body reach the cerebral cortex. It is also the origin of the descending analgesic pathways . The nerve fibers in these pathways act in the spinal cord to block the transmission of some pain signals to the brain. 4. Sleep and consciousness - The reticular formation has projections to the thalamus and cerebral cortex that allow it to exert some control over which sensory signals reach the cerebrum and come to our conscious attention. It plays a central role in states of consciousness like alertness and sleep. Injury to the reticular formation can result in irreversible coma. 5. Habituation - This is a process in which the brain learns to ignore repetitive, meaningless stimuli while remaining sensitive to others. A good example of this is when a person can sleep through loud traffic in a large city, but is awakened promptly due to the sound of an alarm or crying baby. Reticular formation nuclei that modulate activity of the cerebral cortex are called the reticular activating system or extrathalamic control modulatory system.

Manducatory postural reflex

Oculomotor postural reflex

Spinal postural reflex

Adaptive postural reflexes

Role of the myofascial system ?? 

Communication of the Anterior and posterior muscle chains

Chapter 3 Development of the postural system

Maturation of the postural system 

From birth  14 months ◦ Integration and learning of postural control starts with the visual and vestibular information ◦ Schema descendant


14 months  6-7 years ◦ Integration of walking ◦ Stabilization of the hips ◦ Maturation of mechanoreceptors and proprioception of the lower limb


From 8 years till …. ◦ Integration of all systems ◦ Schema a double sens

Chapter 4

Analyzing normal posture

Analyzing standing posture

How to analyze standing posture 

Establishing guidelines in 3 D ◦ Coronal plane ◦ Sagittal plane ◦ Transverse plane

How to analyze standing posture



Coronal plane (frontal plane) Vertical Line that passes: •Occipital protuberance •Spinous processes •Sacral tubercles •Coccyx

Verticale de Barré


We analyze:

•

Acromio-clavicular joints

•

Inferior angle of scapulae

•

Iliac crest

•

PSIS

•

Gluteal folds

•

Creases of knees

•

Straight Achilles Tendon




Coronal plane (frontal plane)





Erector spinae hypertrophy

Evaluation of the Achilles tendon Tightness of the soleus




Coronal plane (frontal plane) ◦ We Analyze:      

The visual axe The mandible Clavicles Space between arms and body Knees Arches of the feet






Coronal plane ◦ analyzing translation +++


Sagittal plane Line passes: •Posterior

border

of

the

mastoid

process •Center of the acromioclavicular joint •Center of the coxofemoral joint •Center of the lateral malleolus


Sagittal Plane


Sagittal Plane


Sagittal plane


Transverse Plane


Transverse Plane

How to analyze dynamic posture

How to analyze dynamic posture 

Gait ◦ Gait is the manner in which walking is performed and can be normal, antalgic, or unsteady. Gait analysis can be assessed by various techniques but is most commonly performed by clinical evaluation incorporating the individual's history, physical examination, and functional assessment

How to analyze dynamic posture There are (4) major criteria essential to walking. 

Equilibrium: The ability to assume an upright posture and maintain balance.



Locomotion: The ability to initiate and maintain rhythmic stepping



Musculoskeletal Integrity: Normal bone, joint, and muscle function



Neurological Control: Must receive and send messages telling the body how and when

to move (visual, vestibular, auditory, sensori-motor input)

How to analyze dynamic posture: 

Gait: ◦ Gait is organized in a cyclic movement of the lower limbs, these cycles are symmetric and reproducible. The gait cycle is a sequence of motion occurring from heelstrike to heelstrike of the same foot. ◦ The spine and the upper limb adapt the lower limb movement in a symmetric and cyclic way. ◦ The transition of the movement is made at T6-T7 “unitéfonctionnelle pivot”


The Gait Cycle ◦ 2 phases : stance and swing ◦ Stance phase: 60% cycle, reference limb in contact with the floor  Double support of reception  Single support  Double support of propulsion

◦ Swing phase: 40% cycle, reference limb not in contact with the floor  Initial swing  Midswing  Terminal swing



Stance Phase ◦ Double support of reception (10% cycle)  Both feet are on the ground  The reception is made on the posterior and lateral border of

the heel with 10° of lateral rotation.  The ankle is in neutral position then in 5 to 10° of extension.

◦ Single support (40% of the cycle)  The ankle is in 10° of flexion

◦ Double support of propulsion (10% of the cycle)


1. 2. 3. 4. 5.

Heel contact: ‘Initial contact’ Foot-flat: ‘Loading response’, initial contact of forefoot w. ground Midstance: greater trochanter in alignment w. vertical bisector of foo Heel-off: ‘Terminal stance’ Toe-off: ‘Pre-swing’

How to analyze dynamic posture Stance Phase


Swing Phase

◦ Initial swing or acceleration  Acceleration occurs as the foot is lifted from the floor and, during this time, the swing leg is rapidly accelerated forward by hip and knee flexion along with ankle dorsiflexion

◦ Intermediate swing  Midswing occurs when the accelerating limb is aligned with the stance limb

◦ Terminal swing or deceleration  Terminal swing occurs as the decelerating leg prepares for contact with the floor and is controlled by the hamstring muscles


1. Acceleration: ‘Initial swing’ 2. Midswing: swinging limb overtakes the limb in stance 3. Deceleration: ‘Terminal swing’

Kinematic of gait cycle

• A = Sagittal plane • B = Frontal plane • C = Horizontal plane

Limb Length Discrepancy

What is leg length discrepancy? 

Leg length discrepancy or anisomelia is an orthopaedic problem that usually appears in childhood, in which one's two legs are of unequal lengths

What is leg length discrepancy? 

3 categories ◦ Structural / anatomical LLD  difference in actual skeletal length of tibia or femur or both  congenital / developmental / traumatic

◦ Functional LLD  bony components are equal in length, but function assymetrically  asymmetrical mechanics / soft tissue contracture

◦ Environmental LLD  uneven shoe wear or banking of roads / athletic tracks  may accentuate, eliminate or reverse an existing LLD

etiology 

Structural / Anatomical ◦ ◦ ◦ ◦ ◦ ◦



Congenital defects Trauma (eg: MVA) Burns Infections Post surgical shortening Tumor

Functional ◦ Muscle contracture (eg: psoas) ◦ asymmetrical rear foot pronation ◦ pelvic / lumbar anomaly (eg: scoliosis)

Incidence and clinical significance 

Incidence ◦ figures range from 60-90% of the general population ◦ longer right leg more common ◦ high correlation with low back pain



no absolute value ◦ depends on ROM, activity ◦ a 3mm LLD may cause symptoms in a runner or someone who spends most of their day standing ◦ greater frontal plane motion of the rearfoot > more significant effect on limb length ◦ generally, treat if causing symptoms or greater than 2 cm

Compensation Of LLD 

As patients develop LLD, they will naturally and even unknowingly attempt to compensate for the difference between their two legs by either bending the longer leg excessively or standing on the toes of the short leg


Can occur in any joint in any plane



Depends on ROM available and size of LLD



Each patient is unique (antecedents)


subtalar joint ◦ pronation of 'long' leg ◦ supination of 'short' leg


Knee Joint ◦ Varum/Valgum ◦ Flexion/hyperextension


Spinal ◦ a number of mechanisms ◦ compensatory sacral drop on the short side may result in: 1. no spinal compensation. Pelvic and shoulder tilt to short side 2. lumbar and cervical scoliosis with shoulder and/ or head tilt to long side 3. lumbar scoliosis with slight or no shoulder tilt to long side

Diagnosis of LLD 

The key to diagnosis is ASYMMETRY in: ◦ ◦ ◦ ◦

Symptoms Shoe wear History of unilateral inversion sprains Conscious adjustment to posture by patient providing symptomatic relief ◦ Asymmetries in gait analysis    

Head/shoulders/arms & spine Pelvic position/drop Hip/knee/ankle/STJ motions Timing of events in gait cycle  Decreased stance time and step  Increased cadence of short limb

Clinical examination of LLD 

Exam of the pelvis ◦ Compare heights 3 reference marks:  Bilateral ASIS level  Bilateral PSIS level  Bilateral Greater Trochantertuberosity level


Comparison of bilateral malleolus level

Clinical examination of LLD Discrepancy of Tibial and femoral length level Alli’s Test 


Alli’s test ◦ Pt. supine - ASIS’s aligned on same frontal and transverse plane ◦ Medial maleolli placed together

◦ View from  above (femoral lengths)  front (tibial lengths)


Clinical measurement of LLD

Radiographic measurement 

Teleradiography ◦ Pt. supine ◦ single exposure on one large film



Scanography (ct scan) ◦ Pt. supine ◦ narrow X-ray beam moved rapidly from one end of a large film to another ◦ Most accurate, less irradiation



Orthoroentgenography ◦ Pt. supine ◦ 3 successive exposures over hips, knees, ankles

Postural analysis of the foot

Foot Evaluation – Why ? 

Essential to standing and walking



Important to postural control



Small change inferior = Large change superior Postural adaptation

Causes of dysfunction 

Congenital ◦ Anatomical deformation



Acquired ◦ Traumatic ( ankle sprain +++ ) ◦ Shoe problem ◦ Not adapted plantar orthosis

Steps for Evaluation 

Observe



Palpate



Muscle examination



Treatment and Recommendation

Observation 

Hip Height Difference



Achilles Tendon Deviation



Medial Malleolus& Internal Arch



HalluxValgus Deviation

Palpation 

The longitudinal arch ◦ ◦ ◦ ◦

Taut Loss of height PesPlanus/cavus Tender

The soleus  Calcaneal tendon  Plantar aponeurosis 

Muscle Examination 

Flexor muscles ◦ Tibialis Anterior, Extensor HallucisLongus, Extensor digitorumlongus, fibularistertius.



Extensors ◦ Gastrocnemius + soleus ◦ Flexor hallucislongus, flexor digitoriumlongus ◦ Tibialis posterior ++



Abduction/ Pronation ◦ Fibularislongus and fibularisbrevis



Adduction / Supination ◦ Tibialis posterior, Flexor hallucislongus, flexor digitoriumlongus

Deformities 

Flatfoot or Talus Valgus ◦ Causes:    

Congenital (hereditary) arthritis ruptured tendon Disease of the nervous system or muscles, such as cerebral palsy, spina bifida or muscular dystrophy

Consequences & Adaptation 

Valgus of the calcaneum



Internal rotation of tibia and femur



GenuValgum

Consequences & Adaptation 2 

Anterior rotation of the pelvis



Increased spinal curves

Deformities 2 

High Arch Feet ( Cavus feet) ◦ Much less common than flat feet ◦ Causes  Congenital (hereditary)  Neurologic disorder

Consequences & adaptation 

Varus of the calcaneum



External rotation of the tibia and femur



GenuVarum



Posterior rotation of the pelvis



Decreases of the spinal curves

Consequences & Adaptation 2

Treatment and recommendation 

Foot Orthoses (podiatry) ◦ Foot orthoses is an orthopaedic device which is designed to promote structural integrity of the joints of the foot and lower limb, by resisting ground reaction forces that cause abnormal skeletal motion to occur during the stance phase of gait



4 Goals

◦ Provide softness or cushioning to increase shock absorption ◦ Provide relief to pressure-sensitive plantar areas to reduce pain under bony prominences ◦ Reduce plantar shearing forces. Shear or frictional forces are an important cause of blisters, calluses, and trophic ulcers ◦ Support or "balance" the joints of the foot in the position most desirable for weight-bearing. This support eliminates the need for the foot to compensate for structural deformity or malalignment between the leg, forefoot, and rear foot

Foot Orthoses 

3 types ◦ Soft inserts: used to provide cushioning to improve shock absorption ◦ Semi rigid inserts: used to provide some softness; however,

they are more commonly selected to provide relief for pressure sensitive plantar areas or to balance the malaligned foot in a neutral position to reduce abnormal foot or leg movement ◦ Rigid inserts: designed primarily to control abnormal foot and

leg motion caused by compensated joint malalignments

Foot orthoses

Treatment and recommendation 

Manual Therapy ◦ Muscle Reinforcement ◦ Joint mobilization ◦ Postural readaptation

POSTUROLOGIE.ppsx

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