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1 J Korean Soc Phys Med, 2014; 9(4): Online ISSN: Print ISSN: X Research Article Open Access 정강종아리관절의활주방향이발목관절의능동적발등굽힘각에미치는영향 고은경 원종혁 1 정도영 1 마산대학교물리치료학과, 1 중부대학교물리치료학과 Effect of Direction of Gliding in Tibiofibular Joint on Angle of Active Ankle Dorsiflexion Eun-Kyung Koh, PhD, Jong-Hyuck Weon, PhD 1, Do-Young Jung, PhD 1 Department of Physical Therapy, Masan University, 1 Department of Physical Therapy, Joongbu University Received: October 12, 2014 / Revised: October 31, 2014 / Accepted: November 3, 2014 c 2014 J Korean Soc Phys Med Abstract 1) PURPOSE: This study was to investigate the effect of direction of gliding in the tibiofibular (TF) joint on angle of active ankle dorsiflexion (AADF). METHODS: Fifteen subjects with no medical history of lower extremities were recruited in this study. The digital dynamometer was used to maintain the same gliding force in each condition. The angle of AADF was measured by using the electronic goniometer. Subjects were instructed to perform the AADF in three trials during the each gliding in the TF joint by the examiner. The conditions were no gliding and four directions of gliding in the proximal (anterior-superior: A-S vs posterior-inferior: P-I) and distal (posterior-superior: P-S vs. anterior-inferior: A-I) TF joint. A repeated measured ANOVA was used to compare angle of the AADF in each TF joint. The paired-sample t tests with Bonferroni correction were used in order to Post hoc pair-wise comparisons. The Corresponding Author : ptsports@joongbu.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. significant level was set at (0.05/3). RESULTS: In distal TF joint, the angle of AADF in the A-I direction of gliding was significantly lower than those in no gliding and P-S direction of gliding (p<0.01). In proximal TF joint, the angle of AADF was significantly lower than those in no gliding and A-S direction of gliding (p<0.01). Although there was no significant differences, angle of AADF were largest in the P-S direction of gliding among four conditions. CONCLUSION: These findings suggest that gliding technique of TF joint would be required to improve the angle of AADF in subjects with limitation of ankle dorsiflexion. Key Words: Ankle dorsiflexion, Gliding, Mobilization, Tibiofibular joint Ⅰ. 서론발목움직임의제한 (limitation of ankle motion) 은발목골절, 염좌, 인대손상과같은정형외과적인흔한질환으로야기될수있다. 이러한발목손상은손상정도에따라발목움직임부동 (immobilization) 을위해몇주동안보조기또는판고정 (plate fixation) 이요구된다 (Denegar 등, 2002; Drewes 등 2009; Lin 등 2009). 집중적

2 440 J Korean Soc Phys Med Vol. 9, No. 4 인치료를받고도발목염좌이후환자의 20 40% 에서발목움직임제한또는지속적인통증이계속된다 (Hertel, 2000). 특히, 발목발등굽힘의제한은일상생활에서심각한문제가된다. 예를들어, 정상보행은최소한 10 의발등굽힘이요구되며계단내려오기와쪼그려앉기와같은동작에서는발등굽힘각도가더요구되므로발등굽힘제한시일상생활에문제가된다 (Collins 등, 2004). 발목움직임을향상시키기위해필요한물리치료방법으로크게관절가동범위운동 (range of motion exercise) 과관절가동술 (joint mobilization) 그리고스트레칭 (stretching) 등이있다 (Green 등, 2001; Whitman 등, 2005). 관절가동범위운동은능동적또는수동적으로반복적인가동범위움직임으로수행되며, 스트레칭은근육, 인대그리고관절낭과같은치밀결합조직의유연성을증가시키기위해사용된다. 관절가동술은관절의부수적인움직임 (accessory motion) 을향상시키는데사용되며관절의기능부전 (dysfunction) 과통증감소를향상시키는데매우효과적이다 (Seiger와 Draper, 2006). 발등굽힘을위한관절가동술은특히발목관절 (talocrural joint), 목말밑관절 (subtalar joint) 그리고먼쪽정강종아리관절 (distal tibiofibular joint) 에주로시행된다. 현재까지임상에서먼쪽정강종아리관절에대한관절가동기법이발목의만성통증을감소시키고발목관절가동범위향상을위해사용하고있다 (Beazell 등, 2012; Fujii 등, 2010; Yeo와 Wright, 2011). Mulligan (1995) 은종아리뼈의위치결함 (positional fault) 즉, 발등굽힘동안가쪽복사가전방으로밀리는것은발목염좌또는발목손상후만성적인발목불안정성으로발생한다고언급하였다. 또한여러연구자들은의해서손상된발목에서위치결함이있음을증명하였다 (Berkowitz와 Kim, 2004; Eren 등, 2003; Hubbard와 Hertel, 2008; Kavanagh, 1999). 그러므로이전연구자들은관절기능부전을가진환자를위해먼쪽정강종아리관절에서의뒤쪽- 위방향으로의관절가동술은종아리뼈의정상적인움직임그리고향상된발등굽힘각도를기대할수있다고주장하였다. 정강종아리관절 (tibiofibular joint) 은정강뼈 (tibia) 와종아리뼈 (fibular) 와연결되어있는관절이며몸쪽과먼쪽의두개의관절을이룬다. 몸쪽정강종아리관절은관절면사이에서활주 (gliding) 가일어나는평면윤활관절 (synovial joint) 로분류되며발목에가해지는외상성내번힘 (traumatic inversion force) 에의해영향을받는다 (Loudon와 Bell, 1996). 먼쪽정강종아리관절은볼록한종아리뼈관절면과오목한정강뼈관절면사이의관절이며발목관절움직임시먼쪽정강종아리관절에직접적인영향을끼친다. 발등굽힘시종아리뼈는위쪽으로활주가일어나고바깥쪽회전즉, 뒤쪽방향으로의활주가일어나야한다. 이러한움직임은뒤쪽면보다앞쪽면이넓은목말뼈 (talus) 에적응하기위해일어난다 (Loudon와 Bell, 1996). 발등굽힘에따라먼쪽정강종아리관절은실질적으로 1 4 mm 정도가벌어진다 (Loudon와 Bell, 1996). 반대로, 발바닥굽힘시부수적인움직임은종아리뼈가아래쪽그리고안쪽회전즉, 앞쪽방향으로활주가일어난다. Fujii 등 (2010) 은발등굽힘각도와가쪽복사뼈움직임의관계를알아보기위해 7개의신선한사체의다리 (fresh-frozen cadaver legs) 를대상으로가쪽복사뼈에뒤쪽 -위방향의 30 N의힘으로 1000번의주기적인하중을주어하중전과후에최대발등굽힘각도를측정한결과 14.3 에서 로 2.38 증가하였다고보고하였다. 따라서먼쪽정강종아리관절의관절가동술은발등굽힘각도를증가시키는데효과적일것이라고주장하였다. 비록이전의많은연구들에서먼쪽정강종아리관절의관절가동술이발등굽힘각도를증가시키는데효과적이다고언급하고있지만, 아직까지몸쪽정강종아리관절의가동술이발등굽힘각도에미치는영향에관한연구는없는실정이다. 따라서본연구의목적은정상인을대상으로몸쪽과먼쪽정강종아리관절의다양한활주방향이능동적인발목관절의가동범위에미치는영향을알아보고자하였다. 따라서본연구의자료는골절과발목염좌와같은발목관절의제한이있는대상자에게발등굽힘의향상을위한관절가동술의기초자료로활용될수있을것으로기대한다.

정강종아리관절의활주방향이발목관절의능동적발등굽힘각에미치는영향 441 Ⅱ. 연구방법 1. 연구대상본연구의대상자에게실험전본연구의목적과방법에대해충분히설명을하였고자발적으로실험에참여하여동의를얻도록하였다. 발목관절의발등굽힘각도가정상이고장딴지근육의신경학적인병력이없고보행에문제가없는성인총 15명을대상으로하였다.

발등굽힘각의표본추출률 (sampling rate) 는 60 Hz로하였다. 발목관절의발등굽힘각을분석하기위해 MyoResearch Master Edition 1.07 XP 소프트웨어를사용하였다. 정강뼈활주를하는동안활주하는힘을일정하게주기위해디지털근력기 (Isoforce GT-310, OG Ginken co. LTD, Japan) 를활용하였다.

3 정강종아리관절의활주방향이발목관절의능동적발등굽힘각에미치는영향 441 Ⅱ. 연구방법 1. 연구대상본연구의대상자에게실험전본연구의목적과방법에대해충분히설명을하였고자발적으로실험에참여하여동의를얻도록하였다. 발목관절의발등굽힘각도가정상이고장딴지근육의신경학적인병력이없고보행에문제가없는성인총 15명을대상으로하였다. 발목관절의발등굽힘각도는엎드린자세에서목말밑관절을중립자세로유지한상태에서일반관절측각기를이용하였다. 발목관절의능동적인발등굽힘각이 20 이하이고하지의골절혹은발목염좌가있으면대상자에서제외시켰다. 대상자의일반적인특성으로평균키 165cm 몸무게 62kg, 나이 22살이었다. 2. 실험방법 1) 측정도구본연구에서발목관절의능동적인발등굽힘각을측정하기위해무선 Telemyo DTS(Noraxon Scottsdale, AZ, USA) 를이용하여측정하였다. 발등굽힘각의표본추출률 (sampling rate) 는 60 Hz로하였다. 발목관절의발등굽힘각을분석하기위해 MyoResearch Master Edition 1.07 XP 소프트웨어를사용하였다. 정강뼈활주를하는동안활주하는힘을일정하게주기위해디지털근력기 (Isoforce GT-310, OG Ginken co. LTD, Japan) 를활용하였다. 2) 실험절차대상자는바닥에앉은자세 (semi-sitting position) 에서무릎관절이 45 굽힘하도록하였다. 발목관절의발등굽힘을측정하기위해디지털관절각도계의몸쪽팔 (proximal arm) 은종아리뼈머리 (fibular head) 와가쪽복사뼈 (lateral malleolus) 을잇는가상선에일치시켰으며먼쪽팔 (distal arm) 은다섯번째발가락각의발허리뼈 (fifth metatarsal bone) 의외측면에부착하였다. 대상자에게발등굽힘을 3번정도연습하는동안에발등굽힘각도가일정하게측정되는지확인한후본실험을실시하였다. 실험자는정강뼈활주시힘을일정하게전달하기위해디지털근력기를이용하여 5명을대상으로충분히예비연습을하였다. 활주힘은지속적병진활주기법 (sustained translatory gliding) 인 Kaltenborn 방법으로관절주위조직이나관절낭이신장되는강도의활주기법인등급 III로적용되었다. 또한움직임을동반한유동술 (mobilization with movement) 과같이대상자가능동적인발목관절을발등굽힘하는동시에정강종아리관절의활주를실시하였다. Fig. 2. Electronic goniometer and direction of gliding Fig. 1. Digital dynamometer to monitor gliding force (A: Controller B: Force sensor) 실험순서는각각의대상자에게우선능동적인발목관절의발등굽힘각을 3회반복측정한후몸쪽혹은먼쪽정강종아리관절의활주방향을무작위로선택하여다음과같은활주방향으로실시하였다. 몸쪽정강종아리관절의종아리뼈활주방향은 (1) 뒤-위방향 (2) 앞-아래방향그리고먼쪽정강종아리관절의종아

4 442 J Korean Soc Phys Med Vol. 9, No. 4 Table 1. Angle of dorsiflexion in ankle joint during the gliding of Distal TF joint (Unit: degree) Direction of Gliding Non gliding Posterior superior Anterior inferior F P Mean±SD 64.06± ± ± Table 2. Angle of dorsiflexion in ankle joint during gliding of Proximal TF joint (Unit: degree) Direction of Gliding Non gliding Anterior superior Posterior inferior F P Mean±SD 64.06± ± ± 리뼈활주방향은 (3) 앞-위방향 (4) 뒤-아래방향으로하였다. 몸쪽정강종아리관절의활주시한손으로오목 (popliteal fossa) 를감싸정강뼈를고정하고디지털압력계의센서를종아리뼈머리에고정하여뒤-위방향과앞-아래방향으로각각활주하였다. 활주시종아리신경 (peroneal nerve) 이압박되지않도록주의하여실시하였다. 먼쪽정강종아리관절의활주는한손의엄지두덩 (thenar eminence) 으로안쪽복사뼈를감싸고정하고디지털압력계의센서로가쪽복숭아뼈를고정하여앞-위방향그리고뒤-아래방향으로각각활주하였다. 각각의대상자에게 4가지조건을 3회씩반복측정하였으며몸쪽혹은먼쪽정강종아리관절의활주시매조건마다 1분씩휴식하였다. 3) 자료분석및통계방법몸쪽과먼쪽정강종아리관절에서활주방향에따라능동적인발등굽힘각도를 3번씩측정하여평균값을대표값으로하여통계분석하였다. 각각의정강종아리관절의발등굽힘각도을비교하기위해반복측정된일요인분산분석 (one-way repeated ANOVA) 를사용하 였다. 이때유의수준은 p<0.05로하였다. 이검증을통해통계학적으로유의한차이가발견되었을때본훼로니 t-검정교정 (paired-sample t tests with Bonferroni correction) 을이용한사후검증을실시하였으며유의수준은본훼로니수정하여 α=0.016(0.05/3) 로하였다. 통계프로그램은 SPSS version 12.0 (SPSS Inc., Chicago, IL, USA) 을이용하였다. Ⅲ. 연구결과 Table 1과 2에먼쪽과몸쪽정강종아리관절의활주방향에따른능동적인발등굽힘각도를각각제시하였다. 먼쪽과몸쪽정강종아리관절의활주방향에따른능동적인발등굽힘각도는각각통계학적으로유의한차이가있었으며 (p<0.05) (Table 1), 사후분석결과, 먼쪽정강종아리관절에서의앞쪽-아래방향의활주조건이활주가없는조건과뒤쪽-위방향의활주조건보다유의하게능동적인발등굽힘각이작았으며 (p<0.01) (Figure 3), 몸쪽정강종아리관절에서의뒤쪽- 아래방향 Fig. 3. Result of post hoc of ankle DF angle in gliding of proximal (A) and distal (B) TF joint * Statistically significant at the level of p<0.016, A-S: anterior-superior, P-I: posterior-inferior, P-S: posterior-superior, A-I: anterior-inferior

5 정강종아리관절의활주방향이발목관절의능동적발등굽힘각에미치는영향 443 의활주조건이활주가없는조건과앞쪽 -위방향의활주조건보다유의하게능동적인발등굽힘각이작았다 (p<0.01) (Figure 4). 비록유의한차이는없었지만먼쪽정강아리관절에서는뒤쪽-위방향의활주가그리고몸쪽정강종아리관절에서는앞쪽-위방향의활주가각관절에서발등굽힘이가장컸다. Ⅳ. 고찰본연구는발등굽힘운동시먼쪽과몸쪽정강종아리관절에서각각의활주방향에따른발등굽힘각도를비교하였다. 연구결과, 먼쪽정강종아리관절에서발등굽힘운동시종아리뼈의정상적인활주움직임의반대방향인앞쪽- 아래방향으로활주시에활주가없는조건과뒤쪽-위방향의활주조건보다유의하게발등굽힘각이제한되었다. 이는발목관절의발등굽힘시먼쪽정강종아리관절에서의바깥복사뼈는뒤쪽- 위방향으로부수적인움직임이일어나기때문에 (Loudon 와 Bell, 1996) 반대방향인앞쪽 -아래방향으로활주가발등굽힘각을제한시켰다. 또한이전연구자들이발목염좌와같은외상시종아리뼈가정강뼈에서앞쪽으로의위치이상으로인해발목관절의발등굽힘제한이야기된다고보고하였는데본연구를통해이를확인할수있었다. 몇몇문헌에서발등굽힘운동시뒤쪽면보다앞쪽면이넓은목말뼈의적응하기위해관절형상학적 (arthrokinematic) 인움직임으로종아리뼈는뒤쪽그리고위로활주가일어난다고언급하였다 (Loudon와 Bell, 1996; Nokin와 White, 1983). 따라서이전연구에서발목관절의제한이있는환자에게먼쪽정강종아리관절을뒤쪽- 위방향으로활주를하면발목관절의가동범위를향상시킬수있다고하였다 (Fujii 등, 2010; Loudon와 Bell, 1996). 본연구에서는먼쪽정강종아리관절의뒤쪽-위방향의활주가활주가없는조건보다통계학적으로유의한차이는없었지만능동적인발등굽힘각도는 1.62 로증가하였다. Fujii 등 (2010) 은사체다리를이용하여가쪽복사뼈에뒤쪽- 위방향으로의주기적인하중 을주기전과후에최대발등굽힘각도는 2.38 로유의하게증가하였다고보고하였다. 발등굽힘각도에대한이전연구비교시차이가나는것은몇가지이유로설명할수있다. 첫번째로는이전연구에서는 1,000번의주기적인하중을주어활주를적용했던것이었고본연구에서는활주를주기적으로하지않고 3번의시도를하여발등굽힘각을측정했다는것이다. 두번째로는이전연구는사체다리이고본연구에서는정상인을대상으로했다는점이다. 세번째로는이전연구는활주만했을뿐이지만, 본연구에서는발목관절의발등굽힘과동시에활주를했기때문에발등굽힘각도의향상정도가차이가났을것으로사료된다. 본연구는선행연구와달리몸쪽정강종아리관절의활주를통해발목관절의가동범위를확인하였다. 몸쪽정강종아리관절의활주방향을앞쪽-위방향과뒤쪽- 아래방향으로결정한이유는반좌위자세에서발목관절의발등굽힘시먼쪽정강종아리관절이뒤쪽-위방향으로움직이게되면몸쪽정강종아리관절이앞쪽- 위방향으로움직일것이라고사료되었기때문이다. 본연구결과, 몸쪽정강종아리관절의뒤쪽- 아래방향의활주가활주가없는조건과앞쪽-위방향의활주보다유의하게능동적인발등굽힘각도를제한시켰다. Loudon과 Bell (1996) 은몸쪽정강종아리관절은관절면사이에서활주가있어나는평면윤활관절로분류되며발목에가해지는외상성내번힘에의해영향을받는다고보고하였다. 따라서, 발목관절의제한이있는발목염좌환자의경우몸쪽정강종아리관절의활주가발목관절각에영향을미칠것이라고사료된다. 본연구에서는몸쪽정강종아리관절의활주가정상인에게서발목관절각에영향을미쳤지만, 향후연구에서는발목관절의제한이있는환자에게몸쪽정강종아리관절의활주가통증과발목관절의가동범위에미치는영향을알아볼필요가있다. 선행연구에서발등굽힙각을증진시키기위한가동기법으로벨트를이용하여정강종아리앞쪽으로활주하는 Mulligan의움직임을동반한유동술 (MWM) 과 Maitland의목말뼈 (talus) 앞- 뒤방향의진동가동기법이있다. 본연구와다른연구와의가동기법의차이점으로는벨트를이용하지않고

6 444 J Korean Soc Phys Med Vol. 9, No. 4 바깥복사뼈를뒤쪽-위방향으로손쉽게할수있다. 또한임상에서환자로하여금목말뼈를가동하면불편함과통증을자주호소하기때문에본연구에서와같이복사뼈를이용한활주기법을추천한다. 그리고먼쪽정강종아리관절의활주가어려운경우몸쪽정강종리관절의활주또한추천한다. 향후연구에서는발목관절의제한이있는환자를대상으로먼쪽정강종아리관절의뒤쪽-위방향의활주와함께몸쪽정강종아리관절의앞쪽- 위방향의활주를적용시그효과를알아보아야할것이다. Ⅴ. 결론본연구는목적은몸쪽과먼쪽정강종아리관절의다양한활주방향이능동적인발목관절의가동범위에미치는영향을알아보고자하였다. 연구결과, 먼쪽정강종아리관절에서의앞쪽 -아래방향과몸쪽정강종아리관절에서의뒤쪽- 아래방향의활주조건이유의하게능동적인발등굽힘각을제한시켰다. 비록유의한차이는없었지만먼쪽정강아리관절에서는뒤쪽 -위방향의활주가그리고몸쪽정강종아리관절에서는앞쪽- 위방향의활주가각관절에서발등굽힘이가장컸다. 따라서발등굽힘각도에제한이있는발목관절의손상그리고장기간고정이있는환자에게장기간의효과를알아보기위해몸쪽과먼쪽정강종아리관절의활주시발등굽힘각의차이를알아볼필요가있을것이다. References Beazell JR, Grindstaff TL, Sauer LD et al. Effects of a proximal or distal tibiofibular joint manipulation on ankle range of motion and functional outcomes in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2012;42(2): Berkowitz MJ, Kim DH. Fibular position in relation to lateral ankle instability. Foot Ankle Int. 2004;25(5): Collins N, Teys P, Vicenzino B. The initial effects of a Mulligan s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains. Man Ther. 2004;9(2): Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprain on dorsiflexion range of motion, posterior talar glide, and joint laxity. J Orthop Sports Phys Ther. 2002;32(4): Drewes LK, McKeon PO, Kerrigan DC et al. Dorsiflexion deficit during jogging with chronic ankle instability. J Sci Med Sport. 2009;12(6): Eren OT, Kucukkaya M, Kabukcuoglu Y et al. The role of a posteriorly positioned fibula in ankle sprain. Am J Sports Med. 2003;31(6): Fujii M, Suzuki D, Uchiyama E et al. Does distal tibiofibular joint mobilization decrease limitation of ankle dorsiflexion? Man Ther. 2010;15(1): Green T, Refshauge K, Crosbie J et al. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Phys Ther. 2001;81(4): Hertel J. Functional instability following lateral ankle sprain. Sports Med. 2000;29(5): Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Man Ther. 2008;13(1):63-7. Hubbard TJ, Hertel J. Mechanical contributions to chronic lateral ankle instability. Sports Med. 2006;36(3): Kavanagh J. Is there a positional fault at the inferior tibiofibular joint in patients with acute or chronic ankle sprains compared to normals? Man Ther. 1999;4(1): Lin CW, Moseley AM, Herbert RD et al. Pain and dorsiflexion range of motion predict short- and medium-term activity limitation in people receiving physiotherapy intervention after ankle fracture: an observational study. Aust J Physiother. 2009;55(1):31-7. Loudon JKBell SL. The foot and ankle: an overview of

7 정강종아리관절의활주방향이발목관절의능동적발등굽힘각에미치는영향 445 arthrokinematics and selected joint techniques. J Athl Train. 1996;31(2): Mulligan BR. Manual Therapy NAGS, SNAGS, MWMS etc. Wellington, Plane view Services Ltd, Norkin CC, White J. Measurement of joint Motion: A Guide to Goniometry, Philadelphia, PA: FA Davis; 1983: Seiger CD, raper DO. Use of pulsed shortwave diathermy and joint mobilization to increase ankle range of motion in the presence of surgical implanted metal: A case series. J Orthop Sports Phys Ther. 2006; 36(9): Whitman JM, Childs JD, Walker V. The use of manipulation in a patient with an ankle sprain injury not responding to conventional management: a case report. Man Ther. 2005;10(3): Yeo HK, Wright A. Hypoalgesic effect of a passive accessory mobilisation technique in patients with lateral ankle pain. Man Ther. 2011;16(4):373-7.

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar