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 isnt 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 isnt 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

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

Strategies to Maintain/Restore
Balance

Strategies to Maintain/Restore
Balance

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

Strategies to Maintain/Restore
Balance

Definitions

Postural control

Postural control
Controlling the bodys
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) ??

The vestibular system

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

Stabilize the eyes relative to the

environment

The vestibular system

Important:
In quiet standing posture, the vestibular system dont
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:
Meissners corpuscles: detects changes in texture
(vibrations around 50 Hz); adapts rapidly
Pacinian corpuscles: detects rapid vibrations (about

200-300 Hz)
Merkels 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

Mechanoreceptors of the
foot

Distribution of cutaneous mechanoreceptors in the foot

Mechanoreceptors of 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.

Mechanoreceptors of the
foot

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

TM Joint Anatomy

The mandible

TM Joint Anatomy

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)

Physiology of the TMJ

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

Physiology of the TMJ

Hinge + translation = ginglymoarthrodial

Physiology of the TMJ

Around a horizontal axe (hinge axe)

Physiology of the TMJ

Physiology of the TMJ

Translation movement or
protrusion

Physiology of the TMJ

Physiology of the TMJ

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

Maturation of the postural system

14 months 6-7 years

Integration of walking
Stabilization of the hips
Maturation of mechanoreceptors
and proprioception of the lower
limb

Maturation of the postural system

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
Barr

How to analyze standing

posture

We analyze:

Acromio-clavicular joints

Inferior angle of scapulae

Iliac crest

PSIS

Gluteal folds

Creases of knees

Straight Achilles Tendon

How to analyze standing

posture

Coronal plane (frontal plane)

How to analyze standing

posture

Coronal plane (frontal plane)

Erector spinae
hypertrophy

Evaluation of the Achilles

tendon
Tightness of the soleus

How to analyze standing

posture

Coronal plane (frontal

plane)
We Analyze:

The visual axe

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

How to analyze standing

posture

Coronal plane (frontal plane)

How to analyze standing

posture

Coronal plane
analyzing translation +++

How to analyze standing

posture

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

How to analyze standing

posture

Sagittal
Plane

How to analyze standing

posture

Sagittal
Plane

How to analyze standing

posture

Sagittal plane

How to analyze standing

posture

Transverse Plane

How to analyze standing

posture

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
unitfonctionnelle pivot

How to analyze dynamic

posture

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

How to analyze dynamic

posture

How to analyze dynamic

posture

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)

How to analyze dynamic

posture

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

How to analyze dynamic

posture

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

How to analyze dynamic

posture

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

Compensation Of LLD

Can occur in any joint in any plane

Depends on ROM available and size of LLD

Each patient is unique (antecedents)

Compensation Of LLD

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

Compensation Of LLD

Knee Joint
Varum/Valgum
Flexion/hyperextension

Compensation Of LLD

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

Clinical examination of LLD

Comparison of bilateral malleolus level

Clinical examination of LLD

Discrepancy of Tibial and femoral length
level
Allis Test

Clinical examination of LLD

Allis test
Pt. supine - ASISs aligned on same frontal and
transverse plane
Medial maleolli placed together

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

Clinical examination of LLD

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