Function of the foot in normal gait 분당 서울대학교 병원 정형외과 이 경 민

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Normal Walking Repetitive sequence of limb movement Purpose Safely advance the body with minimum energy expenditure

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Five Major Attributes Standing Stability Foot clearance during swing Appropriate pre-positioning of foot Adequate step length Energy conservation

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 정상 보행의 추진력 Midstance 의 높은 위치에너지가 terminal stance 에 운동에너지로 전환 Preswing 및 initial swing 시 triceps m. 의 수축 및 iliopsoas 등 hip flexor Early stance 에 G.maxmus 및 hamstring 의 수축에 의한 hip extensor

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL

Gait cycle 한쪽 heel contact 에서 동일 족부의 heel contact 까 지 (0 – 100%) Stance phase: 발이 땅에 닿아있는 시기. 즉 initial contact 에서 toe-off 까지. 60% 차지 Swing phase: 발이 땅에서 떨어져 신체를 이동하는 시기. 동일 족부의 toe-off 에서 initial contact 까지. 40% 차지

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Stance phase

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Stance phase Initial contact Loading response –Ankle rapid PF, forefoot contact Midstance –Ankle DF Terminal stance –Heel rise Preswing

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Swing phase

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Swing phase Initial swing – 하퇴부 가속 Midswing – 하퇴부 가속에서 감속, 근육 작용 없슴 Terminal swing – 하퇴부 감속

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL

Initial contact Ankle neutral Subtalar sl. inversion TA, EDL eccentric contraction Quad. contraction –Loading response 대비 Hamstring contraction –Counteract extension torque

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Initial contact Hip 25 도 flexion Hamtring contraction –hip flexion torque 에 대한 반응

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Loading response Ankle 빠르게 10 도 PF Pretibial m. action Tibia pulled anteriorly Knee flexion Subtalar jt. 4-6 도 외반 Midtarsal jt. unlock

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Midstance Ankle 5-10 도 DF Triceps m. eccentric contraction Knee extension Quad. M. 일시 작용 Hip neutral 까지 extension

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Terminal stance Ankle10 도 DF 1 st MP 30 도까지 extension Triceps m. action Subtalar inversion & midtarsal locking Knee extension 유지 Hip 20 도까지 extension

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Preswing Knee 빠르게 40 도까지 flexion 1 st MP 도 신전 Ankle 20 도 PF

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Initial swing Ankle DF TA, EDL, EHL concentric contraction Knee 60 도까지 굴곡 –Biceps, sartorius, gracilis, active Hip 15 도까지 굴곡 –Iliacus, adductor L active Foot clearance & thigh advance

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Midswing Ankle neutral 위치 TA, EDL, EHL action –Isometric or eccentric Knee 빠르게 25 도까지 extension Hip 25 도까지 flexion –Midswing 의 마지막에는 iliacus, gracilis, sartorius 의 작용 멈춤

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Terminal swing Ankle neutral 위치 Knee 완전 신전 –Quad. contraction Hamstring 수축하여 하퇴부 감속 Hip 25 도 flexion 유지

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Subtalar axis

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Subtalar motion Pronation –DF, abduction, eversion Supination –PF, adduction, inversion

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Midtarsal locking & unlocking Calcaneocuboid Joint Talonavicular Joint

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Loading response Ankle 빠르게 10 도 PF Pretibial m. action Tibia pulled anteriorly Knee flexion Subtalar jt. 4-6 도 외반 Midtarsal jt. unlock

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Terminal stance Ankle10 도 DF 1 st MP 30 도까지 extension Triceps m. action Subtalar inversion & midtarsal locking Knee extension 유지 Hip 20 도까지 extension

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Flatfoot (planovalgus)

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Flatfoot (planovalgus)

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Gait Disturbance Lever arm dysfunction Ankle PF-Knee Ext couple ↓ Pain in talonavicular jt.

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 보행 시 발의 기능적 해석 충격 흡수 안정성 보행의 진행

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 충격 흡수 Loading response 와 early midstance 동안 subtalar jt. 가 점차 외반이 됨 이 시기 내반근이 subtalar jt. 의 외반을 감속 시키 면서 바닥에서 오는 충격 흡수 ( 뒤꿈치가 바닥에 닿을 때는 TA 가 주로 작용, loading response 에는 TP 의 도움을 받음 ) Subtalar jt. 가 외반되면 midtarsal jt. 의 unlocking 으 로 midfoot 이 soft 해지고 충격을 흡수하기에 적합 함

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 안정성 점차 체중이 forefoot 에 실리면서 뒤꿈치 들림 시기 에 이르고 forefoot 으로만 지탱되면 안정성이 최대 로 필요함 (terminal stance) Subtalar jt. 가 내반되면서 midtarsal jt. 가 locking 됨 Terminal stance 에는 Soleus, TP, FDL, FHL 작용 이 현저히 증가

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 보행의 진행 Terminal stance 에 뒤꿈치가 들리면서 MP 족배 굴곡될때, toe flexor 가 작용 발이 땅에 닿아있는 면적에 발가락을 포함시킴으 로써 안정되고 넓은 지지면적 제공 압력 중심 이동이 발 뒤꿈치에서 발가락 끝까지 가능하여 활보장을 증가시키는 역할

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 결론 Subtalar jt. 의 운동이 loading response 의 충격 흡 수 ( 외반 ) 와 terminal stance 의 안정성 ( 내반 ) 제공 Subtalar jt. 운동이 midtarsal jt. 운동성을 조절 Midtarsal jt. 의 운동성 (unlocking) 은 충격 흡수에 기 여하고, 체중이 뒤꿈치에서 전족부로 이동할 때 잠 김 상태 (locking) 가 되어 안정성 제공

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 결론 조절된 MP 관절 운동을 통해 체중 부하 면적으로 발가락 끝까지 증가시키고 보행의 진행이 촉진

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Thank you !