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Information about origins

Published on May 8, 2008

Author: Jolene


Web site:  Web site Mr Nachiappan Chockalingam (Nachi) Principle lecturer in biomechanics, Staffordshire University, England. The Origins of:  The Origins of Podiatric Biomechanics Presented by David N. Dunning Staffordshire England Definition:  Definition Biomechanics is the science that examines forces acting upon and within a biological structure and effects produced by such forces. Hay (1973) Biomechanics is the science which studies structures and functions of biological systems using the knowledge and methods of mechanics. Hatze (1971) Podiatric biomechanics :  Podiatric biomechanics Podiatric biomechanics, therefore, is the study of forces acting on the human body its structure and function with particular reference to the lower limb, the foot and related pathology. Kinesiology and kinematology Slide5:  Kinetics – is the study of forces Kinematics – is the study of movement It is, therefore, the study of movement of the human body, its anatomy and physiology, the forces acting upon it and the effects these forces that have that makes up Podiatric biomechanics. The seven stages of biomechanical history (Nigg):  The seven stages of biomechanical history (Nigg) Antiquity 650BC The middle ages 200AD The Italian renaissance 1450AD Scientific revolution 1600AD The age of enlightenment 1730AD The Gait century 1800AD The twentieth century and beyond “….everything is the sum of the past and nothing is comprehensible except through its history.”:  “….everything is the sum of the past and nothing is comprehensible except through its history.” Paraphrased from Theilhard De Chardin 1959 Antiquity:  Antiquity Pythagoras (582BC approx.) “….all things have form, all things are form, and all things can be defined by numbers” (Attributed to Pythagoras by Koestler 1968) Hippocrates (460-370BC) Emphasised observation and experience and rationalised science – particularly in medicine. “…..chance does not exist, for everything that occurs will be found to do so for a reason” (Attributed to Hippocrates by Sarton 1953) Slide9:  Socrates (471-401BC) “To him whose feet hurt everything hurts” To understand nature we must first try to understand ourselves. Antiquity continued:  Antiquity continued Plato (427-347BC) He sowed the first seeds of mechanics by suggesting that the best tool for the pursuit of knowledge is mathematics. Slide11:  Aristole (384-322BC) Wrote “About the Movement of Animals” - the first scientific analysis of gait. To him observation was paramount. Aristole is also attributed as the first to explain ground reaction forces “…just as the pusher pushes, so the pusher is pushed” (Cavanagh 1990) Antiquity continued:  Antiquity continued Galen (129-201 AD) - probably the first team doctor looking after the college of gladiators. - the father of medicine bringing together anatomy and physiology and writing extensively on the subject with theories that stood uncontested for 1500 years The Middle ages:  The Middle ages Science in all forms stood still during this period in history stifled by the pre-eminence of religion. Galen’s work was the only source of information for any medical practitioners during this period. The Italian Renaissance:  The Italian Renaissance Leonardo DaVinci (1452-1519) “The foot is the most marvellous of machines – and a work of art” A great thinker, mathematician, inventor, military and civil engineer, anatomist and dreamer. He needed to understand human movement to be such a great artist. He graphically illustrated human movement. Slide15:  Vesalius (1514-1564) In “De Humani Corpus Fabrica Libri Septem” he:- - challenged the work of Galen. - he boldly declared that human anatomy [and function] could only be learned from dissection and observation. The Scientific Revolution:  The Scientific Revolution Galileo (1564-1642) The father of mechanics and scientific analysis. Santorio (1561-1636) A colleague of Galileo, applied mechanics to medicine. Harvey (1578-1657) Discribed the mechanical circulation of the blood. Descatres (1596-1650) Along with Malpighi and Borelli held that mechanics rather than chemistry was the key to understanding the functioning of the body. Slide17:  Borelli (1608-1679) In “De Motu Animalium” He described human movement using mathematics and mechanics as well as a good knowledge of muscle function. The father of biomechanics The Scientific Revolution continued:  The Scientific Revolution continued Sir Isaac Newton(1642-1727) “If I have been able to see farther it was because I stood on the shoulders of giants” Galileo, Decatres, Kepler etc His laws of motion provided the impetus to study human movement and the tools to understand it. Newton’s laws (recap):  Newton’s laws (recap) 1st law A body will continue in a state of rest or uniform motion in a straight line unless an external force acts upon it. 2nd law The rate of change of momentum of an object is directly proportional to the force acting, and takes place in the direction in which the force acts. 3rd law To every action there is an equal and opposite reaction. The Age of Enlightenment:  The Age of Enlightenment This is the period of history where the scientific community grew rapidly, as numerous people picked up the baton of the previous age. Newtonian physics flourished and its application to human movement grew through (thru) the likes of d’Alembert and Lagrange. The foundations were laid for the Gait Century. The Gait Century:  The Gait Century Eduard (1795-1881) and Wilhelm Weber (1804-1891) Die Mechanik der menschlichen Gehwerkzeuge’ (On the mechanics of Human gait tools) established an agenda for research into human gait. Braune and Fischer In 1891 1st tri-dimensional study of human gait. Determined the Centre of Gravity of each body segment. Etienne Jules Marey (1838-1904) Edward Maybridge (1830-1904) Etienne Jules Marey:  Etienne Jules Marey Marey was a prolific worker in the field of biomechanics even inventing and using a pressure platform. He also used photography to help in the understanding of human movement. Early motion analysis by Etienne Jules Marey:  Early motion analysis by Etienne Jules Marey Edward Maybridge:  Edward Maybridge Maybridge was a pioneer of photography particularly cine and of human movement. He linked with Marey. The fore runners to twentieth century biomechanics. Slide25:  Henry Gassett Davis (1807-1896) “….soft tissues adapt.” Julius Wolff (1836-1902) The law of bone transformation. The twentieth century:  The twentieth century Early workers Jules Amar “The Human Motor” an analysis of physical and physiological components of work. Bernstein provided the bases of theories of motor control amongst other things. A.V.Hill initiated the understanding of muscle function. Elftman estimated internal forces in muscles and joints – developed a force platform. Post war:  Post war The governments of the day poured money into the developments of programmes to help those injured in the conflict. For example the pioneering work of The California University Biomechanics Lab. At san Francisco and Berkley. The work of so many (too many to mention) pulled together by the likes of Inman and Root Roots’ contribution Like Newton “…..he saw far because he stood on the shoulders of others.” :  Roots’ contribution Like Newton “…..he saw far because he stood on the shoulders of others.” Neutral position Terminology Classification of foot types An understanding of open and closed chain kinetics. The concept of compensation Triplanar motion and its control And more Slide29:  “He who chooses to ignore the lessons of history is doomed to repeat its’ mistakes” (Un-attributed) So what are the lessons of history?:  So what are the lessons of history? How good is the equipment we use? Is it accurate, fast enough, have a good enough resolution, repeatable? Evidence based practice Clinical governance Science versus practice. Aristole v Plato He who pays the piper calls the tune An old Scottish saying Recap Kinematics and Kinetics.:  Recap Kinematics and Kinetics. Anatomy Physiology Physics Observation GHORT Video Pressure mats Motion Analysis Fluoroscopy Anatomy and Physiology:  Anatomy and Physiology Development of anatomical and physiological knowledge through observation, dissection and the testing of hypotheses about function is indicative of the Aristolian approach. Observation is paramount Physics:  Physics The laws of mechanics as epitomised by the work of Sir Isaac Newton and the application of these principles in the understanding of human movement represent the Platonian approach. Note the work of Braune and Fischer. “The best tool in the pursuit of knowledge is mathematics.” Observation and Measurement:  Observation and Measurement Visual Video analysis Pressure mats Motion analysis Fluoroscopy – the future perhaps? The bringing together of the two philosophies. Aristole - observation and evaluate Plato - measure and calculate. Root’s contribution Platonian or Aristolian?:  Root’s contribution Platonian or Aristolian? Neutral position Terminology Classification of foot types An understanding of open and closed chain kinetics. The concept of compensation Tri-planar motion and its control Slide36:  Root with his co-authors –Orien and Weed - brought podiatric biomechanics into the scientific community. Plato meets Aristole What are we looking for in a Podiatric Biomechanical assessment:  What are we looking for in a Podiatric Biomechanical assessment History Signs and symptoms Differential diagnosis (Deductive) Should encompass biomechanical, physiological, psychological, medical, and socio-economic factors. History:  History Essential to the establishment of a diagnosis. Points to the origins of the problem. Gives a patient profile. Helps to set treatment objectives. Signs and Symptoms:  Signs and Symptoms Identify the tissues under stress. May direct patient to other disciplines. Eg. Physical therapy, surgery etc. Guides to systems under stress. Eg. Muscular, vascular, locomotor etc. Differential Diagnosis:  Differential Diagnosis Rules out other pathologies Biomechanical Examination:  Biomechanical Examination Should involve all aspects of investigation because origin of the problem may not be biomechanical. Eg. medical or psychiatric. Should help to identify any other problem areas. Eg. Socio-economic. Rationale for testing (Measuring):  Rationale for testing (Measuring) Helps to identify origin of the problem. May identify several possible origins of the problem. Separate “normal” from “abnormal”. Records useful parameters. Protocol for assessment:  Protocol for assessment Vascular Pulses,Temp,Colour,Doppler,Shape Capillary and venous filling time Neurological:  Neurological Reflexes Muscle tests Sensory, motor and proprioceptive tests Vibration threshold Biomechanical (podiatric):  Biomechanical (podiatric) OKC, CKC and gait examination Joint ROM Muscle testing Rationale:  Rationale Helps to identify morphological origin of the problem. May identify several other possible origins of the problem. Ascending and descending pathology Separates “normal” from “abnormal” for that individual. Protocol:  Protocol Preliminary gait assessment Apply GHORT as per Sutherland. Valmassy, RL. (1996)pp………… Tabulation of sagittal and transverse plane OKC examination. Non weight bearing subjective analysis of range, direction and quality of motion including asymmetry. GHORT:  GHORT Triplanar assessment:  Triplanar assessment Temporal assessment of the gait cycle as suggested by Root (1971) Perry (1992) and Dananberg (1993). Footwear assessment:  Footwear assessment Static and dynamic. Fuller, E. (1994). Conclusions:  Conclusions Assessment should lead to origin and diagnosis of the presenting complaint. Refer onto other disciplines if necessary. Assessment should lead onto appropriate and agreed treatment programme. Assessment should lead to agreed patient/clinician outcome. (Something that can be measured) G.H.O.R.T.:  G.H.O.R.T. The credit for this goes to:- Dr Charles C. Southerland,Jr., DPM. Which is taken from:- “Clinical biomechanics of the Lower Extremities.” Ed. Valmassey R. (1996) Mosby. St Louis Gait Homunculus Observed Relational Tabular:  Gait Homunculus Observed Relational Tabular This is a quick and easy but thorough method of charting both static and dynamic anomalies. Recording is usually - TBFR Top to Bottom Front to Rear Usually shows points of Maximum Compensation, or a point in the gait cycle showing a trend in compensation. G.H.O.R.T.:  G.H.O.R.T. G.H.O.R.T. Rearfoot positions.:  G.H.O.R.T. Rearfoot positions. G.H.O.R.T. Forefoot representations:  G.H.O.R.T. Forefoot representations G.H.O.R.T. Completed.:  G.H.O.R.T. Completed. Rootarian foot biomechanics:  Rootarian foot biomechanics Root with his co-workers –Orien and Weed - brought podiatric biomechanics into the scientific community. Their work is now often referred to as a “Paradigm” What is a Paradigm?:  What is a Paradigm? “A pattern that may serve as a model or example.” Mosby’s Medical,Surgical and Allied Health Dictionary A theory that has an application. Current Podiatric Biomechanical Paradigms:  Current Podiatric Biomechanical Paradigms Patterns of thought that are models applicable in the clinical situation. Presented by:- David N Dunning Staffordshire UK Slide62:  The Root model. The Sagittal-plane facilitation-of-motion model. (Danenberg) The Kirby model. The Fuller model. The tissue stress model. The Demp model. Rootarian principles:  Rootarian principles Neutral position Terminology Classification of foot types An understanding of open and closed chain kinetics. The concept of compensation Triplanar motion and its control Neutral position:  Neutral position There has to be a point at which a joint is neither pronated nor supinated. Every joint has to have a neutral position. Usefulness Terminology “Words are like coins, symbols of the exchange of human thought” R.A.Knox (1914):  Terminology “Words are like coins, symbols of the exchange of human thought” R.A.Knox (1914) We need terms of reference before we can begin. There has to be a common understanding. Root developed terms for motion, position and deformity. One man’s varus could be another man’s invertus Foot types:  Foot types Criteria for normalcy. Is this A flat foot A pronated foot An everted heel A valgus heel Rear foot varus Fore foot varus/valgus Or just a woman with knock knees Open kinetic chain:  Open kinetic chain Root’s examination protocol involves prone, non weight bearing examination of structures to determine RoM, QoM, neutral position and anomalies. Closed kinetic chain:  Closed kinetic chain Root also advocated a closed chain (close packed) weight bearing examination to determine STJt neutral. Neutral Calcaneal Stance Position (NCSP) and Relaxed CSP. Compensation (normal and abnormal):  Compensation (normal and abnormal) Newtonian physics shows that every action has a reaction, but until Root put together the details of foot function the concept of compensation as a pathological issue was not fully grasped. (What for example would The sagittal plane facilitation theory be with out the concept of compensation) – more later. The Dynastat. (Closed chain evaluation that also shows some compensations):  The Dynastat. (Closed chain evaluation that also shows some compensations) Triplanar motion:  Triplanar motion Root’s understanding of triplanar motion is embodied in the foot orthoses he developed. Control can only be fully achieved if motion in all three body planes is addressed. Likewise because the foot mainly functions in all three body planes – what affects one plane will inevitably affect the others. The trouble with the Root model (Taken from Payne C B 1997):  The trouble with the Root model (Taken from Payne C B 1997) 1 understanding the terminology. 2 validity of the criteria for normalcy. 3 validation of the STJt. Neutral position. 4 reliability of the clinical placement of STJt. Neutral. 5 confusion over the midstance STJt. Position. 6 poor inter- and intra- tester reliability. 7 static measurement as a predictor of function. The trouble with Root continued:  The trouble with Root continued 8 poor inter- and intra tester reliability when taking a neutral cast. 9 variations of orthoses made on the same cast. 10 lack of evidence that soft tissue reflects osseous alignment. 11 doubt as to the existence of fore foot varus. 12 lack of clear evidence of compensatory pathomechanics. The trouble with Root continued:  The trouble with Root continued 13 lack of randomised controlled trials. 14 abuse of orthoses by clinicians. 15 true hinge type joints in the foot? 16 invalidity of the two-axis midtarsal joint model. 17 confusion over the stability of the STJt. when pronated or supinated. The Sagittal plane facilitation of motion model :  The Sagittal plane facilitation of motion model This is based on the innovative work of Dr. Howard Dannenberg DPM New Hampshire USA (Functional Hallux Limitus [FHL]) Functional Hallux Limitus:  Functional Hallux Limitus Dannenberg discovered, with the help of the Electro Dynogram (EDG) that, in some patients, when the foot is pronated then the 1st. MPJt., will not freely dorsi-flex. He concluded there must be some form of sagittal plane blockade of the joint. This results in a disruption of normal support i.e. the calc-cuboid JT, the windlass effect and the wedge and truss affect. FHL:  FHL With the 1st ray allowed to plantar flex in an open chain situation the 1st MPJt. Appears to have full range of movement. FHL:  FHL Apply a small amount of pressure and the MPJt. Resists dorsi-flexion Hubscher’s manoeuvre Classification (Prior):  Hubscher’s manoeuvre Classification (Prior) Grade O – no motion 1 – Hallux only 2 – Hallux and arch 3 – Hallux arch and rotation of the leg. FHL:  FHL When the STJt. Is held in neutral then the 1st MPJt shows an increased range of motion. If there is no joint pathology then this motion is equivalent to its’ passive range. Common Hullux Limitus-type Compensatory Motions:  Common Hullux Limitus-type Compensatory Motions Early heel off Adductory twist Internal tibial torsion Circumduction-type gait Early Knee flexion Excessive medial knee pain Decreased thigh extension Trunk bends and upper body sways Excessive pelvic tilt Flexed and hunched back gait Diminished arm swing Head forward or tilted down Treatment – aim to increase available motion:  Treatment – aim to increase available motion Strapping in the early stages to allow 1st metatarsal plantar flexion. Heel lift. Orthoses to reduce pronation and allow 1st ray function – kinetic wedging, forefoot posting etc. High and Low Gear Propulsion:  High and Low Gear Propulsion Oblique – Low gear 2nd to 5th Met heads Transverse – High gear 1st and 2nd Met. Heads As described by :- Bojsen-Muller (1979) High gear:  High gear Tight plantar fascia. Windlass effect Active peroneal muscles. Close packed Calc-cuboid joint Dorsiflexion at the 1st MPJt. Effective wedge and truss action. Dannaeberg’s three main criteria for normal walking. Low gear:  Low gear Most of the soft tissues are lax – creates fore foot instability by reducing re-supination. Plantarflexed Hallux – to try and stabilise the medial aspect of the forefoot. The Kirby Model:  The Kirby Model Dr Kevin Kirby DPM Assistant professor of Podiatric Medicine at the California College of Podiatric Medicine Axeses of the STJt.:  Axeses of the STJt. In the transverse plane 16° from the sagittal plane. In the sagittal plane 42° from the transverse plane. Manter (1941) Root et al (1966) Slide88:  According to Kirby these axes are subject to wide variation within the population and these variations can be clinically significant. Planal dominance theory of the oblique axis. (Green and Carol 1984) Medial and lateral deviation of the longitudinal axis. Normal axis of STJt.:  Normal axis of STJt. Manter 1941 and Root 1966 state that this angle should on average 16 degrees from the sagittal plane. Kirby has the angle a little less. A) Normal B) Medial C) Lateral:  A) Normal B) Medial C) Lateral Method of determining longitudinal axis deviation.:  Method of determining longitudinal axis deviation. Hold the foot gently by the 5th met. Head. Keep the foot vertical Feet at normal base of gait. Fore foot congruous with the rear foot. The thumb holding the 5th met. Head is a detector of movement. :  The thumb holding the 5th met. Head is a detector of movement. Starting on the posterior medial border of the foot push vertically until the point is reached where there is neither pronation nor supination. Mark the spot. Gradually work up the foot.:  Gradually work up the foot. Continue until there are four or five marks to be joined.:  Continue until there are four or five marks to be joined. The axis should be from the lateral 3rd of the heel through to the middle of the Hallux.:  The axis should be from the lateral 3rd of the heel through to the middle of the Hallux. This is a medially deviated STJt. Longitudinal axis.:  This is a medially deviated STJt. Longitudinal axis. There is no superficial indication that there will be a variation in the axis:  There is no superficial indication that there will be a variation in the axis This is laterally deviated.:  This is laterally deviated. In this case a fore foot post will only serve to increase pronation at heel lift.:  In this case a fore foot post will only serve to increase pronation at heel lift. Pressure on the lateral side of the axis will be pronatory. Pressure on the medial side of the axis will be supinatory. Hence the Kirby skive:  Hence the Kirby skive To increase the ground reaction force on the medial side of the axis an angle is ground into the positive cast on the medial 2/3rds of the heel. The fore foot is neutrally balanced The Fuller model.:  The Fuller model. Dr Eric Fuller DPM The California college of Podiatry. San Francisco Slide104:  This builds on the work of Dr Kirby concerning rotational equilibrium. Dr fuller suggests that this is achieved by determining the moments of force about the STJt axis. moment = force x distance Slide105:  The position of sub talar joint longitudinal axis is found using Kirby’s method as described above. Slide106:  The centre of pressure (CoP) line is determined using a pressure/force mat. CoP Lateral to the STJt. Axis (Type 1):  CoP Lateral to the STJt. Axis (Type 1) Fuller concludes that this foot type will have a greater propensity to ponate as ground reaction forces will be pushing in that direction. However, there must be an equal and opposite force within the foot to couter this and maintain equilibrium. He identified three structures that would resist this pronatory moment. :  He identified three structures that would resist this pronatory moment. The Plantar Fascia The Osseus floor of the Sinus tarsi Tibialis Posterior Muscle Test is to use examiners fingers to gauge the force on the lateral side of the forefoot Plantar Fascia:  Plantar Fascia Plantar fascitits The fascia is tight when standing and there is still some RoM available in the STJt Hallux Limitus Tight windlass effect closes the 1st MPJt at fore foot loading Hallux Valgus Tight fascia produces a flexion moment at the Hallux which increase the valgus deformity The Osseus Floor of the Sinus tarsi:  The Osseus Floor of the Sinus tarsi The plantar fascia is slack. No more STJt RoM The calcaneus will not evert from its’ RCSP Fore foot is loaded on the lateral side Propensity to sinus tarsi syndrome Tibialis Posterior muscle:  Tibialis Posterior muscle Plantar fascia is variable in its’ tension There is avariable amount of STJt. RoM The loading on the lateral fore foot is high when the muscle is tense Propensity to Tibialis Posterior dysfunction/tendinitis. Flexor retinacular pathology. The CoP line is beneath the STJt. Axis (Type 2):  The CoP line is beneath the STJt. Axis (Type 2) Fuller refers to this as a balanced foot (Rotational equilibrium is established about the STJt) No related pathology. CoP line is Medial to the STJt Axis (Type 3):  CoP line is Medial to the STJt Axis (Type 3) Fuller suggests that this foot type is very rare. Talipes equinovarus is an example Propensity to peroneal tendinitis, recurrent ankle sprains, high lateral instability. Treatment regimes:  Treatment regimes This model is based on stresses that build up in structures as a result of a lack of equilibrium, therefore, treatment is based on regaining that state. Fuller advocates using orthoses with wedging designed to shift the load off the structures under stress. Putting the CoP line as close to the STJt. Longitudinal axis as possible. The Tissue stress model:  The Tissue stress model Dr Thomas G. McPoil Gary Hunt Physical therapists USA Slide117:  McPoil and Hunt suggest emphasising the tissues under stress rather than the measurement of anomalies and their correction. They propose to very keenly identify the area of stress and by what ever means (usually a combination of regimes) help the body to cope with that stress. The Demp model:  The Demp model Dr Philip H. Demp DPM Podiatrist and Mathematician Philadelphia and New Jersey USA Slide119:  “The foot is a complex, highly variable, multidimensional, biological structure. A desirable model should fit the anatomical configuration of the foot, satisfy the foot’s physiological requirements, and produce a classification of sufficient refinement to discriminate between clinically significant variations in the biostructure of the foot” Demp (1979) Slide120:  This mathematically relates changing pedal contours based upon an ellipsoid which produces a nonlinear model enabling description of mathematical variations in foot size and shape quantitatively. Human feet can thus be classified as a continuum of points representing the entire range of morphologic variation; each point constituting a distinct taxonomic unit or foot type. Slide121:  From this work a it may be possible to produce a biomechanically optimum foot which has ideal function (as opposed to “normal function”) giving the clinician a quantitative rationale for the diagnosis and treatment of mechanical foot disorders. This model is purely theoretical and does not take in the non biomechanical factors in foot pathology ie arthritides. In conclusion:  In conclusion Each paradigm has merit but there is not one that over rides all the others. Each has clinical significance some more than others. Each one adds to our “body of knowledge”. The future – Demp’s model Intra structural force vectors (fluoroscopy). Web site:  Web site This presentation is designed to be put on a web site for reference. Feel free to browse any time.

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