Giovanni Alfonso Borelli Father of Biomechanics 1608-1679 Peter Guy BSc DCh Private practice Whitby and Peterborough Professor Chiropody Faculty Michener Institute of Education at UHN Advisory Board Member Paris Orthotics
We recommend that clinicians stop using sub-talar neutral position during clinical assessments and stop assessing the nonweight bearing range of ankle dorsiflexion, first ray position and forefoot alignments and movement as a means of defining the associated foot deformities.
Critics of the study, cite it s unwise to discontinue the use of the Root protocol until it has been disproven using kinetic, pressure, EMG and inverse dynamics measurements.
We treat pain injury and immobility caused by abnormal internal forces and not so much the motion. I think we need do some type measurement but it has to be linked to the loads we are trying to modify We need research to see if there is a correlation between ground reaction forces, foot deformities, and loading.
www.bartoldbiomechanics.com / articles / miscellaneous / an-approach-to-foot-orthoticprescribing-more-than-meets-the-eye
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1. Accurately identify the anatomical structure which is injured or symptomatic. 3. Determine the most likely type of abnormal tissue stress which is causing the pathology within the injured anatomical structure (i.e. compression, tension or shearing stress). http://www.podiatry-arena.com/podiatryforum/showthread.php?t=1559 Kevin Kirby post Jan 22, 2006
Important Gait Indicators o Evidence short leg. o Re-extension of knee and hip o In toe and out toe problems. o Early or late heel lift. o Pronation during propulsion. o Supination during contact o 1 st MPJ dorsiflexion o Clawing of lesser digits
Eyes open Eyes closed how long the patient can stand on one leg in eyes open or closed situations before going off balance. Try it with patient standing on a foot orthotic for comparison
Heel rocker Ankle rocker Forefoot rocker http://www.rehab.research.va.gov/jour/02/39/1/hafnerf05.jpg
Anterior cavus can be identified in the sitting position. A heel lift can be used to prevent rocking back compensation.
https://www.youtube.com/watch?v=jcpzixgvpmc
Method ICC TAPE.99 INCLIN.98 GON.96
L of E III - C
Identify if there any loss of forward progression of the tibia due muscle or joint problems
Diagram courtesy Kevin Kirby DPM
If there is a severe supination moment acting on the STJ you can observe tonic activity in the peroneal tendon by instructing the patient to supinate their foot and relax in that position. Kirby, K.A Subtalar Joint Axis Location and Rotational Equilibrium Theory of Foot Function JAPMA 91(9): 465-487, 2001
Primal Pictures
Anterior 2nd cuneiform 3rd cuneiform cuboid P.longus tendon 2nd, 3rd, 4th, 5th metatarsal bases Middle N-C joint capsule Navicular tuberosity 1st cuneiform Posterior Sustentaculum Tali Primal Pictures
The tibialis posterior muscle strength can be tested by plantarflexing the foot and pressing against plantar half of the 1st metatarsal head while the patient actively inverts. Picture courtesy of Doug Richie DPM
Peroneal muscle strength can be evaluated by placing the forefoot area in a supinated position and asking the patient to resist the force. Picture courtesy of Howard Danenberg DPM
It is easier to perform exercise standing on a FO
Foot Shortening Exercise 1. Stand on one foot by balancing against wall 2. Raise arch by lifting all toes off the ground 3. Slowly lower toes back to ground and maintain arch without curling toes 1. Raise arch of the foot without curling toes 2. Hold for 10 seconds 3. Relax foot posture
I have observed that patient s standing on a FO find the test easier to perform
Identify if there is any loss of forward progression of the tibia due to the 1 st MPJ or muscle problems
https://youtu.be/wczxk4tu0n8
The plantar fascia via the Windlass mechanism and the intrinsic foot muscles will resist the foot bending during heel rise. If the 1 st MPJ cannot dorsiflex the Windlass will not work. The MTJ has to reach a rotational equilibrium Calf muscles Tibialis posterior m. Body weight Calf muscles Tibialis posterior m. Body weight Terminal Stance Calf muscles Tibialis posterior m. Plantar fascia, plantar ligaments, and plantar muscles will stretch while bones will compress on the dorsal surface Mid-tarsal joint Mid-tarsal joint Mid-tarsal joint 1 st toe joint 1 st toe joint 1 st toe joint
The single leg raise or tip toe test will quickly demonstrate if the mid-tarsal joint is unstable. Heel lift can be inhibited by the. lack of leverage & pain
The supination lag test is evaluated in the sitting position with the feet plantar flexed while the patient brings the soles of the foot together. You need to consider the use of an AFO if the supination lag is positive. Abboud: J, Kupcha P: Supination Lag as an Indication of Posterior Tibial Tendon Dysfunction. Foot Ankle 19:570, 1998
Greater pronation control will be required, if the feet you are evaluating are maximally pronated, difficult to resupinate, and difficult to initiate the windlass mechanism. If there is a loss of translation between the foot and leg you must consider an AFO.
Video courtesy of Mark Bradley DPodM
https://www.youtube.com/watch?v=6fknlicapp8
Wrobel JS. Connolly JE. Beach ML Associations Between Static and Functional Measures of Joint Function in the Foot and Ankle. JAPMA 94(6): 535-541, 2004
Depending on the stiffness of the 1 st MPJ it may require a manipulation
The manual resupination test when performed by experienced clinicians can determine the amount of supination moment needed to supinate the foot. It can be used as a guide to select the level of pronation control in the orthotic. Noakes H., Payne C. The Reliability of the Manual Supination Resistance Test JAPMA 93(3): 185-189, 2003
Inverted heel Heel stabilizer Heel Skive Heel skive Heel stabilizer
A temporary heel skive can be adhered on to the heel cup using 3 layers of 1/8 felt padding.
McPoil TG, Cornwall MW Use of the Longitudinal Arch Angle to Predict Dynamic Foot Posture in Walking. JAPMA 95(2):114-120,2005
L of E IV -C
1. With finger only, where does it hurt? 2. When does it hurt most? 3. As precise as possible how long has it hurt 4. Is there any burning or tingling 5. Are you generally well 1. Single leg hop 2. Single leg squat 3. Jacks test/fhl test/tightness of plantar fascia 4. Supination resistance test 5. Lunge test 6. Intrinsic muscle testing 7. Tightness of calf and hip extensors
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Diagram courtesy Kevin Kirby DPM