PowerPoint 프레젠테이션

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1 Foot Orthoses Prescription for Arch Height Disorders - Pes planus and Pes cavus- 인제의대일산백병원재활의학과 교수이홍재 M.D.

2 목차 1. Pes planus and pes cavus foot 의생체역학적특징과연관질환들 2. Foot orthoses 제작방법들 / 처방가이드라인 3. Foot orthoses 착용실패요인들과대처방법

3 현재의처방실태?! 1. 질환명도기재없이. 예 ) insole 2. 질환명만기재한후 Ex-1] 평발 ; Ex-2] 평발, 뒤꿈치통증 3. 질환명 + 몇가지처방추가 Dx: flatfoot with midsole pain, R/O PTTD Rx: rigid Insole with medial arch and forefoot cushion 단순처방문제점 : 제작자의능력에전적으로의지

4 적절한처방을위한선결과제 환자의상태를정확하게이해 진단명 발생원인발과하지에대한생체역학적지식!! 발보조기에관한지식 종류, 재료 처방법 제작과정, 양형석고본의수정과정 제작과정상의실수로인한문제점 발보조기의외부수정, 추가수정에대한지식 적절한발보조기

5 Pes planus and pes cavus foot Pes planus Overpronation related problems 족저근막염, 중족골통, 지간신경종, 무지외반증 후경골건부전, 장무지건염, 장족지건염 관절염 : ankle, STJ, midfoot, MTPJ 앞정강이통증, 슬개대퇴동통, 대둔근근막통, 기계적요통 Pes cavus Oversupination related problems 족저근막염, 뒤꿈치통증증후군, 비골건염 외측발목염좌, 발가락변형 ITB friction SD, 중둔근근막통, 기계적요통

6 Pes planus 유발원인에대한이해 1. Ligament laxity 2. Equinus or achilles tightness 과회내 (overpronation) 관련문제들 + 중족지골관절통증 3. 1 st ray hypermobility related problem 과회내 (overpronation) 관련문제들 + 1 st ray problems

7 Achilles tightness Related Problems Lack of ankle DF 1. forefoot overload, 2. Compensatory DF by STJ excessive pronation and Midtarsal jt excessive supination I. Forefoot Overload metatarsalgia, callus claw toe II. III. Overpronation of STJ overpronation related problems Midtarsal Jt oversupination unlocked Midfoot Midfoot arthritis

8 1 st ray hypermobility related problem 1 st ray hypermobility DF of 1 st ray during stance phase foot overpronation Problems 1. 1 st ray problems: arthritis, sesamoditis, bunion, HAV,. 2. Overproantion related problems

9 Pes Cavus by Plantarflexed 1 st ray Foot supination 조장 Oversupination related problems 으로표출

11 발보조기치료원칙 1. 적절한발보조기 (foot orthoses) 착용 2. 적절한신발 3. 운동치료 : achilles Stretching 등

12 Rigid or semirigid FO 선택가이드라인 1. Indication for Rigid FO 1. Flexible, moderate to severe flat foot in children and adolescent : heel valgus (RCSP) 5 and more 2. Flexible moderate to severe flat foot in adult : heel valgus (RCSP) 5 and more 2. Indication for Semirigid FO 1. mild flat foot with Foot pain (child, adult) : heel valgus <5 2. Rigid flat foot in adult 3. Rigid cavus foot 4. Erect foot with forefoot problems (Metatarsalgia )

13 Orthotics for pes planus 1) flexible flat foot : rigid >> semirigid ( ㅍㄱ ) 2) rigid flat foot : semirigid orthotics

14 Goal for the Functional Foot orthoses for pes planus To restore normal foot function To stabilize and support the foot Support the subtalar joint as close to its neutral position Allow a normal sequence of subtalar and midtarsal joint motion during stance phase

15 To change joint motion: limit or increase Designed for controlling more flexible foot Usually made by more rigid, supportive materials Ex 1. UCBL 2. FO made by Standard tech, Root tech, Blake s Inverted tech, medial heel skive tech,,,

16 Pes planus 를교정하는기법들 1. Simple arch supports, ready made FO Flexible, semirigid FO // 가벼운평발 2. Heel stabilizers, UCBL 기법 3. Standard tech 4. Root tech 5. Inverted tech 6. Medial heel skive tech (intrinsic medial heel wedge) - Rigid/semirigid - Custom molded

17 UCBL 1967, Univ. of California Biomechanics Laboratory, San Francisco. To treat Flexible flatfoot Fashioned over weight-bearing impression Combination of Whitman-Roberts plate and type C heel stabilizer high medial and lateral flanges + deep heel cup Restrict abnormal motion rather than initiate normal movement and function Widespread uses 단점 bulky, no rearfoot post

18 UCBL 의진화 1. Sustantaculum tali pad supports medial calc and talus Limits motion of STJ (pronation) 2. Rearfoot post stabilizes rearfoot motion

19 Foot orthosis fabricated by standard technique - Adult, forefoot varus/ forefoot valgus 제작 > 1. rearfoot in vertical position(o ) Heel bisecting line 이수직되게위치 2. anterior platforming for forefoot varus 전족에비는공간이생기는만큼석고로채워넣음 3. arch forming 4. tissue extension 5. Rear foot post

20 positive cast in vertical position(0 ) Forefoot varus

21 Root functional foot orthosis - Adult, forefoot varus/ forefoot valgus

22 The Root functional FO 1. Merton Root, Purpose 하퇴 ( 경골 ), 전족, 후족의 deformity 를교정함으로써, STJ and MTJ 의안정성을유지 입각기전체에걸쳐정상적인기능을제공 비체중부하거골하관절중립위치에서석고본뜨기 제작시, 내재또는외재포스팅을추가

23 3. Pouring angle : not vertical position (f/f angle + STJ neutral angle + tibial angle(neutral standing) 4 ) / 2 4. Forefoot varus 를추가적으로교정하도록양형석고본을수정 5. 단점 : 과다한전족부수정으로, 정상적인 1st ray PF motion 이차단되어 Low back pain 생김

24 Modified root tech 개념 : forefoot deformity 를 forefoot 에서전적으로수정하지않고, 절반만수정하고나머지절반각도는후족 ( pouring angle ) 에서교정 Ex ] Forefoot varus 10/10 heel vaglus, pronated foot 제작처방 : forefoot varus 교정 5/5 + rearfoot pouring angle +5/+5 로세팅

25 Blake s inverted technique 1986 Richard L Blake Inverted : 전족을지면에고정한상태에서후족을 inversion 시킨다 Control point calcaneus medial side ( 아래에서위로받쳐올림 ) (sustantaculum tali, talar head, navicular) Ix: More than 5 degree everted heel(rcsp:-5,-6,..) 소아 pes planovalgus 치료 처방요령 : Pouring angle = 원하는교정각 * 5 ex) 5 everted RCSP => 처방시 : pouring at 25 inverted

26 Blake technique -indication Calcaneal position over 5 everted Severe pronation Internal femoral torsion Posterior tibial tendon injury Forefoot varus over 6 degrees 소아 > 성인

27 Blake technique not to use Genu recurvatum Chronic lateral ankle instability Peroneal tendinitis, fibular stress fracture, inversion ankle sprain Forefoot or midtarsal symptoms d/t forefoot valgus or plantarflexed first ray deformities => oversupinated foot

28 Inverted technique 과정

31 25 도 inverted technique 사용 : rearfoot angle 25 도 inversion 되게.

32 Positive cast work: plantar side work navicular 위치가정점으로잡고아치를새로만든다

33 Inverted orthosis

35 Talus (head) controlling technique

36 RFO : Rigid Foot orthosis TCFO : Talus controlling Foot orthosis

37 Change of values of CP and RCSP - 10 세전후, 1 년간착용후 f/u data Calc pitch angle Resting calc stance position (* P<0.05) RFO : Rigid Foot orthosis (n=20) TCFO : Talus controlling Foot orthosis (n =20)

38 Change of values of CP and RCSP - 두군간변화량을비교

39 1. Rotational equilibrium of talus 2. Forefoot dorsiflexion stiffness

40 Semirigid FO 1. readymade insole

41 Semirigid FO 2. custom molded / triple layers 1.Top : accomodative material plastazote 2.Middle : cushioning material Poron 3.Bottom ( shell ) : semirigid material 제작방법 1. negative casting: -partial weight bearing 2. positive cast 3. cast 수정없이보조기재료들을덧씌운다 4. extrinsic forefoot/rearfoot posting

42 Foot orthoses for pes cavus ㅍㄱ Semirigid >>>> rigid 제작주안점 foot deformity + available STJ motion 남은경우는 deformity 교정 : intrisic/extrinsic posting Cushioning 많이

43 Cavus foot 을교정하는기법들 - intrinsic posting methods- 1. Standard tech, Root tech 비어있는전족외측을채워서 heel vertical position 이되도록수정 2. Fettig modification 3. Feehery modification = CCA - Rigid/semirigid - Custom molde 4. lateral column modification 5.Intrinsic lateral heel skive technique 6.Denton modification (lateral forefoot wedge) 하지의임상생체역학, 제 22 장참고

44 Standard technique for cavus Positive cast work: reatfoot 이수직위치가되게하여전족부를수정

45 1 st ray cut-out technique for PF 1 st ray 족저굴곡된제 1 열로인해발이회외되어, 회외관련질환들이생길때 족저굴곡된제 1 열을수용할수있도록발보조기의제 1 중족골자리를낮추거나또는잘라낸다.

46 Extrinsic posting to readymade insole

47 타저서의제작기법소개

52 발보조기치료실패의치료요인 1.In flat foot Orthotics 1.Too much low /high arch, S. tali padding 오류 2.Blocking of normal pronation motion 3.Forefoot abduction : 전족이외측으로미끌어짐 2. In cavus foot orthotics 1. less control of supination force 2.Less cushioning

53 실패요인들에대한대처방안 1. 재제작 1. 아치높이를변경하여처방 2. 기존발보조기에내, 외측에웨지붙이기 1. 아치높이가모자랄때 : 내측전후에모두웨지붙이기 아치부위에 poron padding 을추가 2. 아치높이가너무높을때는외측전후에웨지붙이기 3.Polyprophylene 수지로된보조기의아치낮추기 - 센열 (torch) 을직접가해아치를무게로눌러서

54 BFO with wedge

55 미국에서사용중인처방용지

57 처방 samples 1. 소아평발 : flexible 2. 어른평발 : nonrigid 3. 요족 (PF 1 st ray)

58 Case 1 : 소아 M/7, 체중 35kg CC: Pes planovalgus Association problem: forefoot abductus, sole pain, intermittent anterior knee pain 기립시종골각 (RCSP): -10/-10

59 발보조기처방목적 1. 소아기 flexible flatfoot control. 2. Forefoot abductus 교정 처방시고려사항 1. 환자나이를고려하여총교정각계산 2. 7세때기립시종골각- 0도 ; 현재환자종골각 -10/ 총교정각 : 10도 /10도 4. 첫착용시교정각은총교정각의약 2/3 정도 첫번째발보조기처방교정각도 : 7 도 /7 도 처방 1. Shell material: 4mm polypropylene 2. overpronation control Inverted technique : 35 / 35 Lateral flange 3. cork topcover

61 Case 2 : forefoot varus 의한 flat foot F/45, 체중 55kg Dx: flat foot + Lt plantar fasciitis for 6 months Association problem :both hallux valgus Foot examination STJ ROM WNL Non-Rigid foot 기립시종골각 (RCSP) Lt: -5 Rt: -5 후족에대한전족각 Forefoot varus Lt: +6 Rt: +5 Compensated forefoot varus ( 전족내반변형이후족에모두영향을주었다는뜻 )

Case 2 에대한자세한처방 발보조기처방목적 1. Foot overpronation control. 2. heel과 fascia 에걸리는충격과장력을줄인다 3. 전족부이상을조절 상세처방내역 1. Shell material: rigid (4mm polypropylene) 2.

62 Case 2 에대한자세한처방 발보조기처방목적 1. Foot overpronation control. 2. heel과 fascia 에걸리는충격과장력을줄인다 3. 전족부이상을조절 상세처방내역 1. Shell material: rigid (4mm polypropylene) 2. Foot overpronation control : Inverted tech ( 소아교정량의절반처방 ) Inverted tech : 10/10 3. plantar fascia accommodation 3/3 mm + heel cushion with poron 4. forefoot multifoam extension to toes + 2,3 MT metadome(met pad)

65 Case 3 M/35, 체중 70kg Dx: peroneal tendinitis Associated problems: high arch foot, callus on 5 th MT head and lateral heel Foot examination 기립시종골각 : +7/+7 전족각 : -7/-7 Plantarflexed 1 st ray (+/+) Plantarflexed 1 st ray!! Oversupination-related problem!!

66 발보조기처방목적 1. oversupination control. 2. PF 1 st ray 조절 상세처방 1. Shell material: semirigid 2. oversupination control : standard tech 사용 Heel bisection angle 수직위치가되게 (f/f valgus Lt -7 / Rt -7 ) Plantarflexed 1 st ray cut-out tech. CCA(calcaneocuboid arch), both 3. Full length poron cover (cushioning 위해 )

68 Foot Biomechanics Conference by Prescription Foot Orthosis Laboratory Association, 2007

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