米兰整骨学院-结构性整骨-足骨-跟骨-课件

结构性整骨

足骨1TecnoBodyOsteopathicAcademyTecnobody整骨学院Milano–Italy米兰-意大利2Underthetalus,cuboid,navicularbehindthecouple.And‘themainboneofthefootisfromapointofviewofthestaticanddynamic.距骨之下，骰骨舟骨之后。不论从静态还是动态来说都是足部重要的一块骨Static:becauseitreceives50%ofthebodyweightandalsobecausethearcandtheouterarcendingontherearinnerandoutertuberosityofthecalcaneus.静态：因为承受身体50%的重量，而且它的内外侧两个突起构成足弓和足外弓后部Dynamicbecauseitconditionsthephysiologyoftheforefoot.动态：因为它是影响前足生理机能的重要因素thecalcaneus跟骨3UPPERSIDE上面Ananteriorsegmentthatpresents2articularsurfacesthatcorrespondtothetalus:afacetanteriorinnerconcave(convextalus)andaposteriorfacetouterconvex(concavetalus).Betweenthe2sides,thegrooveoftheheelareaofinsertionoftheleg.Interosseous.前段有两个与距骨相切合的骨面：前内侧凹（对应距骨凸面）和后外侧凸（对应距骨凹面）。在两者之间是跟骨沟。4UNDERSIDE:下面Frombehindforwardisconcave,andconvextransversely.Ithasthreetuberosity,onefrontandonerear.前面为凹面，后面为凸面。拥有三个突起，一前一后。Thetuberosityisanteriorinsertionoftheplantarligamentcalcaneocuboidcuboideo.Theposteriortuberosityhas2processes:themedialadductorhalluxgivesinsertiontotheflexordigitorumbrevisandthesquarefoot;thesidegivesinsertiontotheabductormusclesofthe5thfingerandthesquarefoot.结节是足底韧带跟骰骨处前附着点。后结节有两个突起：中间为拇内收肌、趾短屈肌和足底面附着点；侧边为5个趾外展肌和足底面附着点5EXTERNALSURFACE:外侧面presentsthetuberclewhichgivesinsertiontotheperonealmuscles(alsocalledprocesstrochlear),overwhichpassestheshortlateralperonealandabovepassesalongthelateralperoneal有一结节为腓骨肌附着点（也被叫做滑车结节），其上为腓骨短肌和腓骨外侧肌Laterinthiswehaveaprominenttuberclewhichgivesinsertiontothecalcaneal-fibularligament(ligamentexternalbeammiddlecompartment).在后一些的位置上有一个很重要的结节，是跟骨-腓骨韧带附着点（韧带外束中间的分隔）6INSIDE:内侧面Weobservethecalcanealshower,whichrunsfromtheposteriortuberositysustentaculumsuchinternal.观察跟骨shower，从后结节到支柱内侧Justbelowthesustentaculumsuch,thereisashowerflowingwiththeflexordigitorumlongusandtheflexorunderthisrighttoe.在支柱下，我们可以看到shower从趾长屈肌和右趾下屈肌Thesemusclessupporttheinternalarc,(incaseoffallofthisarcmayhaveapredispositiontohalluxvalgus)这些肌肉支撑着足内弓（防止此足弓塌陷，有拇趾外翻倾向）7FACEBACK:AtthebottomservesastheinsertionoftheAchillestendon.Aboveisthebursa,whichseparatesitfromthetendon后面：在底部是跟腱的附着点。往上是囊，将它与跟腱分开FRONTSIDE:前面isobservedmainlythearticularfacetwiththecuboid主要是与骰骨接合的骨面89Leg.Fibular-calcaneal,mediumbeamofthefundoutsideoftheankle;腓跟，踝外侧中束Leg.Deltoid,thebeamsurfaceoftheinnercompartmentoftheankle.三角，踝中间的表面Leg.talocalcanealrearwhichisthecontinuationoftheposteriortalofibular;距跟后韧带，是距腓后的延伸leg.talocalcanealoutside.距跟外Leg.Interosseous,frontandrear.骨间韧带，前后Ligaments韧带10Leg.calcaneus-navicularexternalbeamthatcorrespondstotheinternalligamentYChopart,sagittal.跟舟外束与跗横关节内韧带对应，矢状Leg.heel-cuboideointernalcorrespondingtoexternalbeamYChopart:thisishorizontal.跟骰内韧带与跗横关节外韧带对应，水平Leg.cuboideoheel-upper骰跟上Leg.cuboideoheel-less骰跟小Calcaneus-navicularligamentglenoidorless.跟舟韧带，关节窝或小Ligaments:韧带1112Thecalcaneusasseenhastwofacets,oneantero-internal(concave)andaposteriorouter(convex)withanaxisinforwardandout.跟骨主要有两个面，一个前内面（凹）和一个后外面（凸）因此在向前和向外形成了两个轴Theaxisisperpendiculartothemobilityofthefacetwillthenforwardandinside.轴是垂直于关节面，向前内Therefore,theaxisofthecalcaneusorAXISHENKE,goesfromtheinsideoftheneckofthetalus,passingthroughthethetarsalsinusandtowardsthepostero-externaltuberosityofthecalcaneus.Ithasadirectionfromtoptobottom,frominsideout,fromfronttoback.因此，跟骨轴或henke轴，从距骨颈内侧，穿过跗骨窦朝向跟骨的后外侧突。方向是从顶到底部，从内到外，从前到后Axisofmotion:运动轴13Inthephysiologyofmovementofthefootisthemalleolarclamp,inparticularthefibula,whichregulatesthephysiology.在足踝运动的生理学中，踝是锁紧的，特别是腓骨，保证了生理活动Analyzingthefootwehardlyanisolateddysfunctionofthetalusorcalcaneusbutoftenwedysfunctionsassociatedwitheachother.分析足部的时候，通常不会有单独跟骨或距骨的功能失常，而往往是二者一并发生Inthemovementofinversion,plantarflexion:•Thefrontofthecalcaneusorizontalizzaandgoesdowninfront;•Thetaluswillgoupbehindoff.Soyouwillhaveaninternalanteriorcalcaneus,taluswithrespecttotheposteriorexternalheelbutearlierthanthecaliper.InthemovementofEversion,dorsiflexion:•thefrontoftheheelishighandgoesbehindverticalizesout,•Astragalusgoesdownaheadinside.Soyouwillhaveaposteriorheelexterior,interioranteriortaluswithrespecttotheheel,butcomparedtotherearcaliper内翻跖屈：•

跟骨前部水平且向下•

距骨会跟着向上会导致跟骨内前，距骨后外，但比夹角要早外翻背屈：•

足跟前部抬高然后逐渐垂直•

距骨向前内会导致后外的跟骨，内前的距骨相对于踝，与后夹角对比14Osteopathictestforthecalcaneus跟骨的整骨测试Testtoheel足跟测试horizontalorverticalprone水平或者俯卧垂直Testtoheel足跟测试eversionorreversalfromaproneposition卧位时外翻或者内翻Testtoheel足跟测试Horizontalorvertical水平或垂直eversionorinversion外翻或内翻patientsupine患者仰卧Testtoheel足跟测试eversionorinversionwithpatientSupine外翻或内翻，患者仰卧位15Thetestsaredoneintraction/decompression.测试在牵拉或者减压情况下进行Thetesthorizontalisationissimultaneouslyalsoanormalizationofverticalandviceversa.水平测试同时也是标准垂直测试，反之亦然Thetestinversionissimultaneouslyreducedtoaheeleversionandviceversa.内翻测试同时引起踝外翻，反之亦然Forexample,toperformanormalizationofreversalwillplacemeasatestofsubversionandtraction,andIwilldecoattazionethree/fourtimesthemaneuverwithoutreleasingthetension.例如，进行正常的反复内翻时还应该做外翻和收缩，在不放松的情况下重复3-4次Correctiontechniques调整技术16Correctionforheelvarus(inversion)足踝内翻调整Patientoutofbedontheleftfootwiththemedialfaceupwards.患者左足伸出治疗床外，踝内面向上Operatorwiththeinnerpartofthethighdorsiflexesthefoot,handfixesthecranialtibiaandthecaudalhandontheheelleads“downwards”,valgizzandotheheel(tosubversion)操作者利用大腿内侧背屈足踝，靠近躯干的手固定胫骨，靠近足部的手置于足跟“向下”压，使足踝外翻Correctionforheelvalgus(eversion)足踝外翻调整Patientoutofbedontheleftfootwiththefacesideup.患者左足伸出治疗床，踝外侧面向上Operatorwiththeinnerpartofthethighdorsiflexesthefoot,handfixesthecranialtibiaandthecaudalhandontheheelleads“down”varizzandotheheel(toreverse)操作者利用大腿内侧背屈足踝，近端手固定胫骨，远端手置于足跟“向下”压，使足踝内翻17Theyareverycommonatthislevel.在这个水平上常见Theywillmeetwhenevertherewillbeaforcedmovementinreverse(externallateralligamentsprain)oreversion(internallateralligamentsprain)ofthefootandwheneveryoususpectamechanicalsuccessioninterestingascendingordescendinglimbdysfunctionin在被迫的运动中内翻（外侧韧带扭伤）或外翻（内侧韧带扭伤）中，或者怀疑有机械性肢体上下运动损伤DYSFUNCTIONINEXTERNALposterolateral后外向功能失常DYSFUNCTIONININTERNALANTERO前内向功能失常Theresearchofthesedisordersandtheircorrectionwillbemadeinthreedifferentways:这些失常的研究和调整通常有三种不同方式：•Bysettingthetaluscalcaneus调整距骨下的跟骨•Bysettingthetalusonthecalcaneus调整跟骨上的距骨•Actinginpairsonthetwobonesatthesametime同时调整Sub-talarjointdysfunction距下关节18SpacingofChopart跗横关节间隔It‘importanttoevaluateandpossiblytreatittobalanceproperlytheback-footwithallthatliesahead.评估和调整跗横关节至中立平衡位非常重要

Thecranialhandsecurestheheel;thecaudalhandtakescareoftheforefoot,thatputsdorsiflexiontoblockthetalus,thethumbtakescareofthetubercleofthecuboid,theindexofthescaphoidtubercle(thehandsareincontact).Mustmakeatraction-decoattazionefollowingthelongitudinalaxisofthefoottoopenthelinespacing.Thedistalhandmovementswilltake,individuallyandincombination,forinternalorexternalrotationandadductionorabduction.Thecorrectiveaction,asopposedtothetest,willberepeatedseveraltimes.

一手保护足跟，另一手保护前足，背屈以锁住距骨，大拇指放置于骰骨结节处，食指在舟骨结节处（两手接触）。必须沿着足部纵线挤压以打开跗横关节的间隙。远端的手应使足踝联合内旋或外旋，内收或外展。调整手法与测试手法相反，需重复几次19Itconsistsof3parts:-Head(arctic.scaphoid/legglenoid/intfacetanteriorcalcaneus);-Neck;-body(talarpulley).Werecognizefaces6:Superior(body):talarpulley(whichismorewideforward);Lower:has2surfaces,anteriorfacetint(conv)andpostero-east(conc),bothwithoff-axisobliquelyforward;inthemiddle,thethetarsalsinus;External:artic.fibula(lowertriangleatthetop);Internal:artic.tibia(comma-shaped);Rear:showerformuscleFPA,tubercleeast.andint.(bonetrine);Front(head):3presentsthecorrespondingfieldsall‘artic.Scaphoid,theglenoidorlegcalcaneal-navicularbottomthatactsasasupporttothetalus

ASTRAGALUS距骨包含三部分：头（舟骨/腿窝/跟骨前面）；颈；主干（距骨滑车）有6个面：上面（主干）:距骨滑车（前面部分更宽大）下面：2个骨面，靠前（凸）和靠后（凹），都被前轴斜穿过；中间，跗骨窦外侧面：腓骨（上部为低三角）内侧面：胫骨（逗号型）后面：FPA的shower突起前面（头）：切合形状的关节面。舟骨，浅窝或跟舟底，共同支撑距骨20UPPERSIDEorpulleyortrochlea:widerforwardthantherear,fromfronttobackisconvexisconcavetransversely.Duringankledorsiflexiontheclampopens,closesinplantarflexion,becausethetrochleaiswiderbehindthanahead.上面或滑车或：前部大于后部，前部凸后部凹。中间隙在踝背屈打开，在跖屈中关闭，因为上面的滑车的后部要大于前部21UNDERSIDEtwofacetjointsthatarticulatewithhisheel,aposterior-EXTERNALgloballyconcave-shapedoval,withanobliqueaxisforwardandoutandaANTERO-INTERNALgloballyconvexwhosemainaxisisalsoobliquelyforwardandoutward.下面两个骨面与踝切合，一个后外完全椭圆形，轴向为前外另一个前内完全突起，主要轴向也是斜向前外22FACEOUTSIDE:itistheouterextensionofthetrochlea,articulateswiththefibula,hasashapeofaninvertedtriangle,toptobottomisconcaveandconvexintheanteroposteriordirection.Atthelowerendofthearticularfacetofthetaluswefindtheapophysesexternalpointofinsertionoftheleg.talocalcanealoutside.Priortotheneckofthetalusaretheinsertionoftheanteriortalofibularligament(anteriortalarfibularligament).外侧面：是滑车向外的延伸，与腓骨成关节，为倒三角形，顶部到底部为凹面而前后向为凸面。在距骨下端的关节面可以看到距跟外侧附着点的突起。在距骨颈前是距腓韧带前端的附着点（前距腓韧带）23INSIDE:Internalextensionofthetrochleaarticulateswiththetibia.Articulationcomma-shapedmasshorizontally.Priortotheneckofthetalushavethetalaranteriortibialinsertionoftheligament,posteriortothemedialtubercleofthetibialinsertionoftheligamentligamentposteriortalus.内侧面：滑车向内的延伸与腓骨成关节。关节面为逗号形，大的一端水平。在距骨颈前是距胫前韧带附着点，中间突起的后方是胫骨骺韧带附着点24ligaments:韧带withthefibula(eastcompartment.)和腓骨（东分隔）-Legtalofibularant.;距腓前-Legtalofibularpost;距腓后withtheheel和跟骨-Frontleginterosseous.andpost.(sinustarsi);前腿骨间和后（跗骨窦）-Legtalocalcanealpost.;距跟后-Legtalocalcanealeast.;

距跟东withthetibia(intcompartment.)和胫骨-Tibio-talarfrontleg.;胫距前-Legtib-talarpost.;胫距后withthenavicular和舟骨-Legtalo-navicular距舟25Ligaments:韧带26Betweenthe2articularsurfacesofthelowerface,wefindthethetarsalsinuswiththeinsertionoftheleg.Interosseous.在下表面的两个骨面之间，可以看到跗骨窦和骨间韧带附着点THEAXISOFMOVEMENTONTHEHEELtaluswillbeperpendiculartothefacetjointsLARGEAXLEANDORIENTEDINFORWARDANDINSIDE.足跟运动的轴在距骨上是垂直于关节面。大轴在前部和内部为水平REMEMBER:牢记Thetalushasnomuscleinsertions!距骨本身没有肌肉附着点27Mechanismmanufacturerofadysfunctionofthetalusinpriorart:afallonthefootinplantarflexiondistortionoftheoutercompartmentoftheankle(inversion)Symptoms:paininthedorsalflexion.Testofmobility:towardsgreateramplitudeNachträglichkeitloweramplitudetothepriorart距骨前部功能异常机制踝跖屈时摔倒内翻时外踝扭伤症状：背屈时疼痛运动性测试：朝向最大活动幅度处前部小幅度Mechanismmanufacturerofadysfunctionofastragalusdorsally:afallonthefootindorsiflexiondistortionoftheinnercompartmentoftheankle(subversion)Symptoms:painintheplantarflexion.Mobilitytests:morebreadthtothepriorarttothenarrowestafterwardness距骨后部功能异常机制踝背屈时摔倒外翻时内踝扭伤

症状：跖屈时疼痛运动性测试：前部较后部活动性更大28Testsforassessingstability稳定性评估测试LEG.TalofibularFRONT=frontdrawer前距腓骨=前抽屉试验Operatorsetsthetalusandthetibiaposteriorizzawiththecranialhand,远端手固定距骨近端推胫骨向后Itassessesthesensationoftheendstopandtheendfeel.评估运动感觉LEG.TalofibularREAR=posteriordrawer后距腓骨=后抽屉试验Operatorsetsthetalusandthetibiaanteriorizzawithhandcranial远端手固定距骨近端拉胫骨向前Isevaluatedasabovetheendofstrokeandalsothepresenceofbursts评估障碍点LEG.Fibular-calcaneal=lateraldrawer腓骨跟骨=抽屉测试Itevaluatesthemortarfemoraltibia-fibula评估股骨髁胫骨腓骨Theoperatorliftsthepatient‘slegwithhishandfixedinternalmalleolusandthetalusblocks:withtheexternalhandundertheheelleadsinreverse.操作者一手固定患者内踝，抬起腿锁住距骨：外侧手放在足跟下进行反转LEGtibio-calcaneal=lateraldrawer跟骨胫=侧抽屉Itevaluatesthemortarfemoraltibia-fibula评估股骨髁胫骨腓骨Theoperatorliftsthepatient‘slegwithhishandinsidethefixedlateralmalleolusandthetalusblocks:withthehandundertheoutsidedoorheeleversion抬起患者腿，一手内锁住内侧踝，一手外锁住距骨且外翻患者足29Osteopathictestsfortheastragalus距骨测试OSTEOPATHICTESTFORTHEASSESSMENTFRONTorREAROFASTRAGALUS前距骨\后距骨评估Operatorwiththecaudalhandwiththumbandforefingerundertheanklestolockthetalus(withthefootindorsiflexion);withthecranialhandgraspsthedistaltibiaandcurrencythroughthemovementifthereis:TIBIAPOST.=ASTRAGALUSFRONTTIBIAANT.=ASTRAGALUSBACK操作者在患者足背屈时远端手的拇指与食指放在踝下锁住距骨；近端手握住胫骨远端施展手法治疗，如果存在以下情况：后胫=前距前胫=后距Theoperatorperformsadorsiflexionofthefoot,leaningthebackofthehand(orwithafist)onthesolesofthefeetofthepatient.IfyoufeelalimitationofendfeelofthemovementyouhaveaASTRAGALUSFRONT操作者背屈患者足踝，患者足底顶住操作者手背（或者握成拳头）如果在运动范围中感受到受限，则为前距Theoperatorthenperformsaplantarflexionofthefoot,Aumentadoparameter.IfyoufeelalimitationofmovementyouhaveaASTRAGALUSBACK操作者然后跖屈足踝，增加幅度，如果感觉到运动受限，则为后距30ASTRAGALUSREAR-THRUST(anteriortibial)后距（前胫）thrustTheoperatorwiththecaudalhandblocksthetaluswiththethumbandindexfingerwhilehiscranialhandthatholdsthedistalpartofthetibiasearchthetensiongraduallydorsally'TIBIA(forASTRAGALUSTIBIAFRONTandBACK).Thebarriermustbesoughtinthewayback,thenTHRUST!操作者远端手拇指与食指锁住距骨，近端手握住远端胫骨，向后慢慢寻找障碍张力点（距骨胫骨前或后），然后施展thrustTheoperatorliftsthefootdysfunctionimpalmandothetalusandcalcaneuswithinnerhandwithexternalhand.Youputintensionbybringingthefootinplantarflexion,itinducesasmalldecoattazione,thenTHRUSTtowardsthebottom(andpossiblecomponentforwards)!操作者抬起患者腿，双手一内一外握住距骨，跖屈患者足踝以增加张力，会产生小小的，然后施展thrust向操作者的后方Correctiontechniquesastragalus距骨调整技术31ASTRAGALUSFRONT-THRUST前距(posteriortibial)（后胫）TheoperatorwiththecaudalhandlocksthefootindorsiflexionwhilethebottomwiththehandthatholdsthetaluslookcranialtensionprogressivePosteriority‘talus.Thebarriermustbesoughttowardstheback(andalittle'below),thenTHRUST

操作者远端手背屈踝以锁住足部，另一手拿住距骨向下推，会在往后的过程中找到障碍点，施展thrust技术Theoperatorliftshisfootinthetaluswitherectileimpalmandoinchesbelowthesoleofthefootandtheotherfingersovertheinstep.操作者抬起足部，拇指放置于距骨，其他手指放在足背Youputintensionbydorsiflexionofthefootwithasmalldecompression.通过踝背屈增加关节张力，同时减压Correctiontechniq