足過度旋前對(duì)人體力線的影響及治療方法①

楊平，蔡麗飛

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足過度旋前對(duì)人體力線的影響及治療方法①

楊平，蔡麗飛

[摘要]在一個(gè)步態(tài)周期中，如果旋前超過支撐期25%，可以認(rèn)為發(fā)生過度旋前，可能由于先天和后天因素導(dǎo)致。過度旋前會(huì)影響脛骨、膝關(guān)節(jié)、股骨、脊柱的力線，導(dǎo)致一系列疼痛綜合征。舟骨下降高度測(cè)試、足部姿勢(shì)指數(shù)是評(píng)定足過度旋前的常用方法，臨床?；诮?jīng)驗(yàn)評(píng)定。有效的保守治療方法包括足矯形器、特種鞋、肌力訓(xùn)練和貼扎技術(shù)。

[關(guān)鍵詞]足；過度旋前；力線；慢性疼痛；足部矯形器；貼扎；綜述

作者單位：1.首都醫(yī)科大學(xué)康復(fù)醫(yī)學(xué)院，北京市100068；2.中國(guó)康復(fù)研究中心康復(fù)工程研究所，北京市100068。作者簡(jiǎn)介：楊平(1983-)，女，漢族，山東沂南縣人，碩士，助理研究員，主要研究方向：康復(fù)工程。E-mail: yangping2005668@163.com。

[本文著錄格式]楊平，蔡麗飛.足過度旋前對(duì)人體力線的影響及治療方法[J].中國(guó)康復(fù)理論與實(shí)踐, 2016, 22(1): 72-74.

CITED AS: Yang P, Cai LF. Foot overpronation: influence on body alignment and managements (review) [J]. Zhongguo Kangfu Lilun Yu Shijian, 2016, 22(1): 72-74.

1　定義及原因

1.1定義

足部的綜合運(yùn)動(dòng)包括旋前和旋后[1]。所謂旋前是指足的外翻、外展、背屈，主要發(fā)生在距下關(guān)節(jié)[2]。該關(guān)節(jié)是一個(gè)三平面運(yùn)動(dòng)關(guān)節(jié)，包括矢狀面的跖屈/背屈、額狀面內(nèi)翻/外翻、水平面內(nèi)收/外展。旋前時(shí)，跟骨外翻，距骨內(nèi)收、跖屈。整個(gè)踝足部表現(xiàn)為踝背屈、距下關(guān)節(jié)外翻、跗橫關(guān)節(jié)外展[1]。在一個(gè)步態(tài)周期中，從足跟觸地到支撐中期發(fā)生旋前，以減少來自地面的震動(dòng)。支撐中期足放平時(shí)旋前量最大。如果旋前超過一個(gè)步態(tài)周期支撐期的25%，就可以認(rèn)為是過度旋前[2-3]。從外觀上看，過度旋前時(shí)足跟外翻或足內(nèi)側(cè)縱弓過度降低，足部變長(zhǎng)[4]。過度旋前會(huì)使蹬離期足部的正常旋后延遲或消失[5]。

1.2原因

過度旋前是對(duì)異常足部軟組織或骨性結(jié)構(gòu)的代償[6-7]。多數(shù)情況下過度旋前發(fā)生在距下關(guān)節(jié)[6-8]。過度旋前的原因可分為先天性和后天性[9]。

先天性原因可能是胎兒在子宮內(nèi)位置不當(dāng)或遺傳所致[9]。Rothbart提出，過度旋前與胚胎發(fā)育過程中距骨發(fā)育異常有關(guān)，即距骨頭未完全解旋(unwinding)，使距骨旋后(talar supinatus)，引起第一跖骨相對(duì)于第二跖骨被抬高、內(nèi)翻[10]，并將這種足定義為Rothbart足。從外觀上看，這種足的第一、二趾間隙變深。當(dāng)站立承重足部處于解剖中立位時(shí)，第一跖列離地面10～30 mm[11]。

后天性原因包括肌肉骨骼系統(tǒng)異常和神經(jīng)系統(tǒng)異常。前者包括肌力下降、肌肉韌帶松弛、雙下肢不等長(zhǎng)等[4]；后者包括腦癱、腦外傷、腦卒中、脊髓損傷等。這種代償性過度旋前通常從幼兒開始站立負(fù)重時(shí)就已形成[12]。

2　對(duì)下肢力線的影響

2.1足正常力線

1977年，Root等提出，應(yīng)該將足視為一個(gè)動(dòng)態(tài)結(jié)構(gòu)，并描述了理想的足部力線[13-14]。從后方觀察，小腿下1/3寬度的等分線與跟骨等分線平行或在一條直線上；從前面觀察，5個(gè)跖骨頭所在的平面與跟骨等分線垂直[4,13]。當(dāng)距下關(guān)節(jié)處于中立位(neutral position)，跗中關(guān)節(jié)必須鎖住，足部才能處在中立位。步行時(shí)，當(dāng)足處于支撐中期和足趾離地期時(shí)，足應(yīng)在中立位[13-14]。?str?m等發(fā)現(xiàn)，足在中立位時(shí)，小腿下1/3寬度的等分線與跟骨等分線呈外翻2°，前足輕度內(nèi)翻6°，站立時(shí)跟骨輕度外翻7°，脛骨內(nèi)翻6°(與垂線的夾角)狀態(tài)[15]。

2.2過度旋前時(shí)的力線

過度旋前會(huì)影響脛骨、膝關(guān)節(jié)、股骨、脊柱的力線[4-7]，進(jìn)一步引起相關(guān)肌肉韌帶過勞損傷，最終導(dǎo)致足痛、膝痛、下腰痛等慢性疼痛的發(fā)生。改變足部受力狀態(tài)可以改變下肢力線[5]，達(dá)到緩解或消除疼痛的目的。

正常足旋前時(shí)脛骨內(nèi)旋，過度旋前會(huì)引起脛骨過度內(nèi)旋[16-20]。跟骨外翻角度與脛骨旋轉(zhuǎn)有密切關(guān)系[16]：跟骨外翻角度越大，脛骨內(nèi)旋角度也越大[18]。支撐初期膝內(nèi)旋角增加，股骨內(nèi)旋角增大[19]，髖關(guān)節(jié)內(nèi)旋角增加[20]，骨盆前傾角增加[20]，骶骨角、腰椎前凸角、胸椎后凸角均增加[21]。足部過度旋前最大時(shí)，脛骨和股骨的內(nèi)旋不一定達(dá)到最大值[22]。雙側(cè)跟骨外翻比單側(cè)跟骨外翻導(dǎo)致的骨盆前傾角更大，單側(cè)跟骨外翻會(huì)引起骨盆側(cè)向傾斜[23-24]。過度旋前會(huì)引起雙下肢功能性不等長(zhǎng)，進(jìn)一步引起骨盆傾斜[25]。

2.3與疼痛的關(guān)系

足弓降低會(huì)增加膝痛、踝痛的風(fēng)險(xiǎn)[26]。過度旋前會(huì)增加脛骨內(nèi)側(cè)壓力，導(dǎo)致脛骨內(nèi)側(cè)壓力綜合征[18]，也會(huì)引起髕股綜合征，尤其會(huì)增加髕股外側(cè)壓力[18,27]。過度旋前與足底筋膜炎、脛后肌腱炎、跖痛癥、拇外翻有密切關(guān)系[26,28]，它也會(huì)增加運(yùn)動(dòng)員膝前交叉韌帶損傷的風(fēng)險(xiǎn)[29]。過度旋前導(dǎo)致雙下肢不等長(zhǎng)，引起骨盆傾斜，進(jìn)而導(dǎo)致慢性下腰痛[30-31]。

3　評(píng)估

過度旋前可以使用舟骨下降高度測(cè)試(Navicular Drop Test, NDT)[16,22,32-34]、足弓高度[34]，足部姿勢(shì)指數(shù)(Foot Posture Index, FPI)[35-39]、休息位跟骨外翻角度(resting calcaneal eversion)和縱弓角度(the longitudinal arch angle)[16,22]等方法進(jìn)行評(píng)定。其中NDT和FPI是常用的兩種方法。

NDT是指雙足站立時(shí)，舟骨結(jié)節(jié)從距下關(guān)節(jié)中立位到跟骨休息位(即放松站立的位置)時(shí)下降的高度。Brody提出舟骨下降高度超過15 mm可以認(rèn)為足部發(fā)生過度旋前，但是沒有證明[32]。

FPI共有6項(xiàng)測(cè)試內(nèi)容，前足和后足各3項(xiàng)，所有測(cè)試均在受試者雙足放松站立時(shí)完成[36-39]，可用于成人和兒童[37]，每項(xiàng)測(cè)試得分為-2～2分。后足測(cè)試包括觸摸距骨頭(足的內(nèi)外側(cè)是否可觸摸到距骨頭)、外踝上下緣的曲線(兩個(gè)曲線的凹陷程度對(duì)比)、跟骨內(nèi)外翻(以內(nèi)翻5°、外翻5°為界)、內(nèi)側(cè)縱弓的一致性(縱弓弧度)，前足測(cè)試包括距舟關(guān)節(jié)的膨出(該關(guān)節(jié)的凹陷、膨出)、前足相對(duì)后足的內(nèi)收/外展(能看見外側(cè)腳趾的數(shù)量)[36-37,39]。10～12分為重度過度旋前，6～9分為過度旋前，0～5分為中立位，-1～-4分為過度旋后，-5～-12分為重度過度旋后[37,39]。男性和女性FBI評(píng)分沒有明顯差異，老年人和兒童的FBI評(píng)分偏高[38]，說明老人和兒童容易發(fā)生足過度旋前。

在臨床工作中，可以從足的外觀、鞋的磨損程度和足的力線等幾個(gè)方面快速判斷足部是否過度旋前。從外觀上看，足發(fā)生過度旋前時(shí)，跟骨外翻，足弓高度降低并變長(zhǎng)，前足外展[2]。從舊鞋的磨損看，過度旋前時(shí)，足底內(nèi)側(cè)受力增大，鞋底內(nèi)側(cè)磨損要比外側(cè)嚴(yán)重；鞋會(huì)向內(nèi)側(cè)傾斜。從足的力線上看，取小腿下1/3寬度的中心(A點(diǎn))、距骨頭中心(B點(diǎn))、第二跖骨頭(C點(diǎn))，當(dāng)距下關(guān)節(jié)處于中立位時(shí)，這3點(diǎn)應(yīng)在一條直線上；過度旋前時(shí)，這3點(diǎn)不在一條直線上，通常AB的延長(zhǎng)線會(huì)止于拇趾內(nèi)側(cè)[40]。這也是拇外翻與過度旋前有密切關(guān)系的原因。

4　治療

對(duì)于足部過度旋前及其引起的慢性疼痛，有效的保守治療方法包括足矯形器[28,31,41-43]、具有運(yùn)動(dòng)控制作用的鞋[42]、肌力訓(xùn)練[28,41,44-45]和貼扎技術(shù)[42,46]。

足矯形器可消除引起過度旋前的足部因素，如前足內(nèi)翻、支撐縱弓[42]，減少下肢異常內(nèi)旋，使各關(guān)節(jié)、肌肉、韌帶處于相對(duì)正常的位置，從而減輕疼痛。

具有運(yùn)動(dòng)控制作用的鞋常用于跑步運(yùn)動(dòng)員，通過鞋跟外展邊或鞋的中底修改，起到減慢足觸地后和支撐中期的過度旋前的作用[42]。

貼扎技術(shù)使用不同材料貼布，控制足部相應(yīng)關(guān)節(jié)的運(yùn)動(dòng)，達(dá)到控制過度旋前的作用[45]。

定制的足部矯形器效果優(yōu)于通用矯形器。具有運(yùn)動(dòng)控制作用的鞋，鞋跟外展或楔形墊設(shè)計(jì)劣于雙密度中底設(shè)計(jì)。在貼扎材料中，治療貼扎(therapeutic adhesive taping)效果最好，無彈性的白色貼布效果最差[42]。

增加足底深層肌肉力量可以增加足弓高度，降低舟骨下降程度[45]，從而減少過度旋前。如“縮足運(yùn)動(dòng)”(short foot exercise)通過鍛煉足底內(nèi)在肌的力量減少過度旋前[44]。

5　小結(jié)

過度旋前是足部最常見的功能異常，它引起人體姿勢(shì)的改變，導(dǎo)致慢性疼痛發(fā)生。重視過度旋前，在臨床治療中綜合使用足部矯形器、貼扎、鞋、肌力訓(xùn)練等方法，對(duì)于它引起的各種足部疼痛、膝痛、下腰痛等慢性疼痛能收到良好效果。

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Foot Overpronation: Influence on Body Alignment and Managements (review)

YANG Ping, CAI Li-fei
1. Capital Medical University School of Rehabilitation Medicine, Beijing 100068, China; 2. Institute of Rehabilitation Engineering, China Rehabilitation Research Center, Beijing 100068, China
Correspondence to YANG Ping. E-mail: yangping2005668@163.com

Abstract:The foot overpronation is termed as pronation persisting more than 25% of stance phase in a walking cycle, which may result from some antenatal or postnatal conditions. Overpronation would lead to abnormal alignment of ankle, knee, pelvis and spine, and result in a set of syndromes of chronic pain. The Navicular Drop Test and the Foot Posture Index are often used as the assessment tools, however, there are several empirical ways for clinic. Foot orthoses, special shoes, taping and training of muscle strength are effective on overpronation as well as chronic pain.

Key words:feet; overpronation; alignment; chronic pain; foot orthoses; taping; review

(收稿日期：2015-07-28修回日期：2015-09-18)

[中圖分類號(hào)]R681.8

[文獻(xiàn)標(biāo)識(shí)碼]A

[文章編號(hào)]1006-9771(2016)01-0072-03

基金項(xiàng)目：中央級(jí)公益性科研院所基本科研業(yè)務(wù)費(fèi)專項(xiàng)資金項(xiàng)目(No.2013CZ-13)。

DOI:10.3969/j.issn.1006-9771.2016.01.015