米蘭整骨-骰骨-課件

1Itislocatedontheouteredgeofthefoot,infrontoftheheelbone,behindthe4thand5thmetatarsal,withrespecttotheoutsidescaphoid.Ithastheshapeofatriangularprism-basedinterior.Ithas5facesand1margin.位于足部外側(cè)緣，跟骨前，4、5跖骨后，相對舟狀骨向外。內(nèi)側(cè)為三棱鏡形，有5個面和1邊緣Cuboid骰骨2Dysfunctionsofcuboid-navicular骰舟關(guān)節(jié)功能失常Duringtheinversionofthefootontheinsideofthecontractionoftheposteriortibialtubercleofthescaphoidintheleadupandback;thenthescaphoidwillmakeainternalrotation,ieitslowerfacewilllookinsideanditsoutsideedgewillslidedown.Thecuboidisalsoattractedtohimintheligamentousattachmentsthatconnectitwiththescaphoid.在足內(nèi)翻中，收縮內(nèi)面脛骨后結(jié)節(jié)，舟狀骨先向上后；然后舟狀骨內(nèi)旋，底面向內(nèi)外緣向下滑。骰骨也因為與舟狀骨有韌帶聯(lián)系而被拉向它Duetotherostrumatthelevelofthecalcanealapophysislargeanditsarticularfacetwiththescaphoid,itwillresultinastopthatwillbringthecuboidboneinexternalrotation(hislowerfacelooksoutside).由于跟骨結(jié)節(jié)平面和與舟狀骨切合的關(guān)節(jié)面，會使得骰骨停止而轉(zhuǎn)向外旋（底面向外）Thismechanismissimilartoagearsprockets.此機制與鏈齒輪一樣Thenavicularhasthentoascendthepredominanceinitsinternaltubercle,whilethecuboidwillhavethetendencytoraiseitsouteredge.舟狀骨內(nèi)側(cè)結(jié)節(jié)上升，骰骨外緣上升3Duringtheeversionofthefootshortlateralperoneal,throughitsinsertionatthelevelofthestyloidprocessofthe5thmetatarsal,thecuboidwillattractoutsideandbackwardswhilethelongperonealsidewillraiseitsouteredge.在足外翻的過程中，腓骨短肌雖然附著在第5跖骨莖突，骰骨會向外后向，而腓骨長肌外緣上升Thecuboidwillmakealimitedexternalrotationfromtherostrumoftheheel.Similarly,thecuboidbone,thenaviculardrag,butevenhere,duetothesurgeoftheposteriortibialandthearticularfacetjoint,therewillbeagearsystemwhichwillresultinanascentoftheinternaltubercleofthescaphoidandadescentofitsouteredge.骰骨會做小幅度外旋從跟骨平面到足跟。同樣地，骰骨，舟狀骨拖拽，但是由于脛骨后緣運動和關(guān)節(jié)面，仍做鏈齒輪運動，最終是舟狀骨內(nèi)結(jié)節(jié)上升外緣下降Youthenexperienceanexternalrotationofthecuboidandinternalrotationofthescaphoid.會有骰骨外旋和舟狀骨內(nèi)旋Dysfunctionsofcuboid-navicular骰舟關(guān)節(jié)功能失常4Scaphoidininternalrotation:?MechanismManufacturer:flatfoot(ifarcislowered),distortionininversionandeversion?Symptoms:paintothescaphoidandelectivelikelypaininthesubtalarjointtothephysiologicallinkbetweenthenavicularandcuboid.?Palpation:morepronouncedinternaltubercleandhigher?Mobility:IncreasedinternalrotationCuboidinexternalrotation:?MechanismManufacturer:flatfeet,sprains?Symptoms:Painonelectivecuboid?Palpation:outeredgeraisedup?Mobility:increasedexternalrotation舟狀骨內(nèi)旋：?機制：平足（足弓低）足內(nèi)外翻異常?

癥狀：舟狀骨痛，可出現(xiàn)距下關(guān)節(jié)痛，舟骰之間的生理聯(lián)系?

觸診：內(nèi)側(cè)結(jié)節(jié)易觸，高?

運動性：內(nèi)旋增加骰骨外旋：?

機制：平足，扭傷?

癥狀：可出現(xiàn)骰骨痛?

觸診：外緣上升?

運動性：外旋增加5Osteopathictestforcuboidandnavicular骰骨和舟狀骨的整骨測試Thehandcephalicimpalmatheheelsoastodetermineafixedpoint近端的手觸摸足跟來感覺受限點?Thedistalhandthroughthehypothenarisrestingontheheadofthe1stmetatarsalandthefootdoesmakeadorsiflexion遠端手的小魚際放置于第1跖骨，足踝做背屈?Thethumbofthehanddistalsettlesonthebottomofthetubercleofthescaphoid,becausetheindexisonthedorsal拇指放在舟狀骨結(jié)節(jié)底部，食指在背部?Theosteopathdoesmakescaphoidmovementofinternalrotationwiththethumbrestandmovementsofexternalrotationwithindexsupport.操作者用拇指使舟狀骨做內(nèi)旋，食指幫助做外旋?Thetestiscomparative進行對比測試Thehandcephalicimpalmatheheel近端手置于足跟?Thehanddistaltothehypothenarontheheadofthe5thmetatarsalistoperformafootdorsiflexion遠端手小魚際置于第5跖骨，足踝做背屈?Thethumbandindexfingerdistalarearrangedrespectivelyonthedorsalandplantarsurfaceofthecuboid拇指和食指分別置于骰骨的足背和足底面?Osteopathsmovethecuboidinthesuperior-inferiordirectiontoevaluatethedysfunction.操作者在上下方向運動骰骨以評估功能失常?Thetestiscomparative進行對比測試6Correctiontechniquesofscaphoid舟狀骨調(diào)整技術(shù)Theinnerhandthroughthethenarcomesintocontactwiththeupperpartofthenaviculartubercle內(nèi)側(cè)手通過大魚際擠壓舟狀骨結(jié)節(jié)上部?Theexternalhandistoperformafootdorsiflexion外側(cè)手背屈足踝?Theosteopathaftersearchingthetensionandtheequilibriumpoint,makesathrustwithhishandinsidetobringdownthetubercleandatthesametime,theexternalhandaccompaniestheinsidehandinmakingthisdescenttoperformamovementofthefoot‘subversionabduction操作者找到張力及平衡點，用內(nèi)側(cè)手施展thrust下壓結(jié)節(jié)，同時外側(cè)手配合使足外翻外展Samepointofcontactwiththeinsidehandonthetubercle內(nèi)側(cè)手放置于同樣的結(jié)節(jié)處擠壓?Theexternalhanddoesmakeadorsiflexionofthefoot外側(cè)手背屈足踝?Theosteopathsearchthetensionandtheequilibriumpoint操作者找到張力及平衡點?Tryathrustwithhishandtolowertheinternaltuberclewhiletheexternalhandraisestheinsideedgeofthefoot,itisthereforedissociatethemovementofthescaphoidfromthatofthecuneiform施展thrust下壓結(jié)節(jié)，同時外側(cè)手將足內(nèi)側(cè)邊緣上提，以此分離舟狀骨和楔骨的運動?CarryoutapairinThrust.進行兩次7Patientintheproneposition,theleg90°患者俯臥，屈膝90度?Theexternalhandpassesontopofthefootand,viathemetacarpal-phalangealjointofthe1°,takessupportontheupperedgeofthetubercle.外側(cè)手置于足背頂部，通過第1掌跖關(guān)節(jié)，給予結(jié)節(jié)上緣支持?Thehandputsaplateontheinnerarchofthefoot,doesmakeadorsalflexion,abductionrealizestheinneredgeofthefootrialzandone另一手掌置于足內(nèi)弓，使足踝背屈，外展至內(nèi)邊緣?Findingthebalance找到平衡點?Tensionandthrustupwards(elbowlow).至張力處向上施展thrust（肘彎在低位）8Patientsupinekneeflexion患者仰臥屈膝位Theinnerhandosteopathimpalmatheheelandstabilizes;thethenarofthehandisrestingontheoutersideedgeofthecuboid(fingersimpalmanothelowerface)andleadstowardstheinternalrotation,ietowardsthemidline.內(nèi)側(cè)手觸摸穩(wěn)定足跟，大魚際放置于骰骨外側(cè)緣（其他手指觸摸底面），內(nèi)旋足踝，使其朝向中線Itcallsforadorsiflexionofthefootbycontinuingtoleadtowardsthecorrection.繼續(xù)引導(dǎo)至正確位置使得足踝背屈Onceinthebarrierwiththesametechniqueyoucandoathrustinthedirectionofinternalrotationofthecuboid.至障礙點時在骰骨內(nèi)旋方向施展thrust技術(shù)Correctiontechniquesofcuboid骰骨調(diào)整技術(shù)9Technique“whip”“抽打”技術(shù)?Patientinprone患者俯臥位?Theosteopathisputatthefeetofthepatient,impalmafootfromthedorsalsurface,withthetwohands,twoincheswidepositioningoftheinneredgeofthecuboidbone,restingonthe操作者雙手置于患者足部，托住足背，剩余兩個拇指約2英寸寬置于骰骨兩個內(nèi)側(cè)緣?Lightweighttractiontotheosteopathlowerlimb,leavinghangingthefoottothegroundtoformthehollowoftime(becarefulnottoputtoomuchplantarflexion!)使用較輕的力量，在足背置于治療床面使向下推擠（注意不要造成過多跖屈）?Tensioningandthrustfromthebottomup.張力點處，從下往上施展thrust10Thecuneiformbonesarethree:1st,2ndand3rd.Theyarelocatedinfrontofthenavicular,cuboidinwardsandbackwardscomparedtothe1st,2nd,3rdmetatarsals.有3塊，第1，第2和第3位于舟狀骨前，骰骨內(nèi)側(cè)和第1、2、3跖骨后Directlyinfluencedbythescaphoidandsitesoverthecrosshaveatendencytobecomehollowtherebyadverselyaffectingthearcandfore-foot.受舟狀骨的直接影響，位于足弓頂部，因此易形成空洞不利于足弓和前足Describedareessentiallytwotypesofdysfunction:?Cuneiformhigher?Cuneiformlower以下為主要的兩種功能失常：高楔骨低楔骨Cuneiform楔骨11Osteopathictestforcuneiform楔骨的整骨測試Theosteopathmobilizescuneiformandheadmovementintheinferior-superiordirectionwithagripbetweenthethumbandindexfingeronthetopandbottomfaceofeachcuneiform操作者以拇指和食指抓住楔骨，在足背與足底方向上測試楔骨的運動性，每個楔骨單獨測試?Theotherhandimmobilizesthecouplecuboid-navicular另一只手同時測試骰舟兩骨的運動性?Thepatientissupineorprone患者可仰臥也可俯臥?ComparativeTest進行對比測試12Technicalsuperiorityincuneiformbones:高楔骨技術(shù)?The3rdcuneiformisthekeystone,thenthereductionsaremadeinthefollowingorder3rd-2nd-1st第3楔骨最重要，接著是第2，然后第1?Technique“bracelet”“手銬”技術(shù)?Patientsupine患者仰臥位?Theosteopathtakesarestatthelevelofthedistalphalanxofthemiddleonthedorsalsurfaceofthewedge-shaped,theotherhandissuperimposed操作者以第3指節(jié)置于楔骨足背面的中間，另一手疊上?Additionalsupportofthethumbsonthebasisofthecorrespondingmetatarsal拇指置于相應(yīng)的跖骨底給予支持?Theosteopathmakesalongitudinaltractionandhaveperformedatafootdorsiflexion操作者施展縱向牽拉，同時使足背屈?Findingthebalancepointandthrustthelongitudinalaxisoftheleg找到平衡點，在足的縱向軸線上施展thrustCorrectiontechniqueforcuneiform楔骨的調(diào)整技術(shù)13Techniqueforcuneiformbonesininferiority:低楔骨技術(shù)?Technique“whip”“抽打”技術(shù)?Patientinprone患者俯臥?Sametechniqueforthecuboidwithsupportontheplantarsurfaceofthecuneiform與之前骰骨調(diào)整中同樣，只是將手置于楔骨足底面予以支持?Tensioning增加張力?Findingthebalancepointandthrustfromthebottomtothetop找到平衡點，從底部向上施展thrust?2nd-1st-3rdcuneiform順序為2、1、3楔骨14Hock-spacingofLisfranc趾跗關(guān)節(jié)的間隔ThespacingofLisfrancseparatesthetarsalfromthegoal.趾跗關(guān)節(jié)間隔將跗骨從goal分離出來Iam5;haveabase(proximal),abodyandahead(distal).跗骨有5塊，一個底（近端），一個體和一個頭（遠端）The1stmetatarsalisthelargestandtheshortest,byinsertionoftheM.tibialisanteriorandM.peroneuslongusside.第1跖骨最大最短，有脛骨前肌和腓骨長肌的附著點The2ndmetatarsalisthelongest.第2跖骨最長The5thmetatarsal,theshortestandsmall,isarticulatedatthelevelofthebaseofthecuboidboneandisimportantforthepresenceofthestyloidwhereitfitsintotheshortperonealside.第5跖骨，最短最小，與骰骨底成關(guān)節(jié)，有一個重要的莖突是腓骨短肌的附著點Physiologicallyperformmovementsofflexion-extensionassociatedwithmovementsofabductionandadductionandaminimumofinternalandexternalrotation.Osteopathicdysfunctionsofthemetatarsalsareevaluatedbasedontheupperorlowerbase.生理學(xué)上存在屈伸，同時有外展內(nèi)收和小幅度的內(nèi)外旋。整骨中關(guān)注上下底的功能失常15Osteopathictestsformetatarsalbones跖骨的整骨測試Theosteopathmobilizesthebaseofeachmetatarsalheadandthemovementinthedirectionofinferior-superiorwithapinchbetweenyourthumbandforefinger.操作者用拇指和食指捏住每一個跖骨頭的底部，在足背和足底方向（上下）上進行運動性測試?Theotherhandimmobilizesthemetatarsalsegmentprecedingthetest同時另一只手在每個跖骨測試前固定其他跖骨，防止其活動?Thepatientissupineorprone患者仰臥或者俯臥?ComparativeTest進行對比測試16Correctiontecniquesformetatarsalbones跖骨的調(diào)整技術(shù)TECHNIQUEFOR1st-2nd-3rdMETATARSUSBASEDTOP對于1、2、3跖骨底向上的技術(shù)?Patientsupine患者仰臥?Theosteopathgrabshisfoot,fingersarecrossedontheupperbaseofthemetatarsalinjuryin整骨師抓住患者足部，手指交叉置于跖骨足背面?Thethumbsarecontrappoggiothecorrespondingmetatarsalhead.拇指置于對應(yīng)的跖骨頭處?Thetechniqueiscarriedoutwithadownwardtractionandthrustwithhisfingersonthedorsalfacedown.拇指進行向下擠壓施展thrust，同時其他手指在足背面給予支持TECHNIQUEFOR4th-5thMETATARSUSBASEDTOP對于4、5跖骨底向上的技術(shù)?Patientsupine患者仰臥?Theosteopathsittingbythesideofdysfunction操作者坐在功能失常一側(cè)?Thelimbdysfunctionisrestingonherthigh功能失常肢置于大腿上?Withthehandthroughtheproximalpisiformcontactonthedorsalsurface,thebaseofthemetatarsal手掌豌豆骨處擠壓跖骨底的足背面?Withthedistalhandthroughthepisiformcontactontheplantarsurface,theheadofthemetatarsal另一只手掌豌豆骨處擠壓跖骨底的足底面?Researchofthebarrierandthrustapair,perpendiculartothelongitudinalaxisofthefoot.找到障礙點，在垂直于足部縱軸的方向上施展兩次thrust技術(shù)17REDUCTION1st-2nd-3rdMETATARSUSBASEDBOTTOM1、2、3跖骨底向下的調(diào)整?Patientinprone患者俯臥?Theosteopathimpalmathefootwithhishands,thefingersarerestingonthedorsalsurface,thetwothumbscomeintocontactwiththebaseofthemetatarsalindysfunction操作者手托住足部，拇指頂在跖骨功能失常處，其他手指置于足背面給予支持?Correctionwithdownwardtractionandthrust向下擠壓施展thrust技術(shù)REDUCTION4th-5thMETATARSUSBASEDBOTTOM4、5跖骨底向下的糾正?Patientindorsalrecumbency患者仰臥?Theosteopathissittingbythesideofthelegdysfunction操作者坐于功能失常肢一側(cè)?Thelimbisrestingonhisthigh功能失常肢置于大腿?Withthepisiformdistalhand,makescontactontheplantarsurfaceofthebaseofthemetatarsalindysfunction遠端手豌豆骨處置于跖骨底功能失常的足底面，進行擠壓?Withtheproximalpisiformhand,makescontactonthebaseofthedorsalmetatarsalinjuryin近端手豌豆骨處置于跖骨底功能失常的足背面，進行擠壓?Researchofthebarrierandthrustapair,perpendiculartothelongitudinalaxisofthefoot找到障礙點，在垂直于足部縱軸方向上施展兩次thrust技術(shù)18Alsoknownasarticulationtibio-fibular也被稱作脛腓接合

Articulationproximaltibialfibular.Artrodiabetweenthelateralcondyleofthetibiaandtheheadofthefibula.Ithasaverystrongjointcapsulereinforcedbythetwoligamentsinfrontandbackoftheheadofthefibula.脛腓近端關(guān)節(jié)。脛骨外側(cè)髁與腓骨頭之間的關(guān)節(jié)，依靠腓骨頭前后的兩條韌帶形成了非常強大的關(guān)節(jié)。

Articulationdistaltibialfibular.Syndesmosisbetweenthelowerendofthetibiaandthelateralmalleolusofthefibula.Therearetwoligamentsatthislevelofthelateralmalleolusanteriorandposterior(slantingtothefibularmalleolusofthetibia).Duringdorsiflexion,thisjointisopenedtoallowtheslidingrearofthetrochleaofthetalus(largerthanbefore).脛腓遠端關(guān)節(jié)。脛骨遠端與腓骨外側(cè)髁之間的韌帶連結(jié)。在此外側(cè)髁水平中也有前后兩條韌帶（斜向）。在背屈中，此關(guān)節(jié)打開以使距骨滑車（后部大于前部）向后滑動。Tibio-fibularjoint脛腓關(guān)節(jié)19Interosseousmembrane.Tesabytheinterosseouscrestofthetibiatothefibula.Basicallyconsistsoffibrousbundlesthatobliquelydownfromthetibiatothefibulaandviceversa.And'thistopalargeorificeforthepassageoftheanteriortibialvessels.Theanteriortibialarteryisthelesserbranchofthebifurcationofthepoplitealartery;theposteriortibialarteryisthelargerofthetwobranches,andgivesascollateralfibularorperonealarterythatbranchesoffthemuscle(nutritiziathearteryofthefibula,posteriormalleolararterylateraltothelateralmalleolarnetwork).Theanteriortibialarteryseparatestheanteriormalleolararteries,lateralandmedialtothemedialandlateralmalleolarnetworksaroundthetibiaandfibula.Youhavetothinkabouttheseifyouhaveproblemsorvascularstasis.Therefore,theinterosseousmembrane,inadditiontobeingamechanicalconnectionfascialchainsofpeculiarinterestinthefunctional(anddysfunctional)parentandchildofthefoot,playsanimportantroleinthehemodynamicsoftheleg.骨間膜脛腓骨間嵴之間的堅硬部分基本是由從脛骨到腓骨或者從腓骨到脛骨的斜向纖維束組成。在它頂端有脛骨前血管穿過，脛骨前動脈是脛骨動脈分支中較小的一支，而脛骨后動脈較大，且形成腓骨旁動脈或者腓動脈，從肌肉處分支，滋養(yǎng)腓骨動脈和踝血管網(wǎng)側(cè)部。脛骨前動脈分支成前踝動脈群，側(cè)部到中間和中間到側(cè)部，分別滋養(yǎng)脛骨與腓骨。如果你有問題或血流淤滯，就必須考慮這些。因此，骨間膜除了是一個在功能特殊的興趣方面正常（和不正常的）聯(lián)系家長和孩子的機械連接筋膜鏈，對腿部的血流動力學(xué)也有重要作用。20Duringtheplantarflexion,thelowerendofthefibuladropsmakesaexternalrotationduetotheconvexityofthetalarfacetintheanteroposteriordirection;Astothemalleolarclamp,itclosesbecausethepulleytalariswiderforwardsandbackwards.在跖屈中，腓骨遠端向下運動且因為距骨在前后軸向上的凸面而產(chǎn)生向外的旋轉(zhuǎn)；踝部夾緊的過程中關(guān)閉，因為距骨滑車的前部要大于后部Duringdorsiflexion,theexternalmalleolusmovesawayfromtheinsidewheelliftsslightlyandinternally.在背屈中，外踝從內(nèi)部移出且輕微向上Theuppertibial-fibularjointmovesaccordinglytotheexternalmalleolus:duringdorsiflexionoftheankletheheadofthefibulasalt.外踝背屈過程中，脛腓近端關(guān)節(jié)相應(yīng)地移向內(nèi)踝側(cè)。Conversely,duringplantarflexion.跖屈相反Biomechanicsofthetibiaandfibula脛骨與腓骨的生物力學(xué)21AtthelevelofthefibularheadpassesthelateralpoplitealnerveinthepoplitealsciaticnervethatforminsidetheterminalbranchesofthesciaticBIGNERVE(lumbosacralplexusorsciaticnerve).在腓骨頭水平為腘神經(jīng)，是坐骨大神經(jīng)的終支（腰骶叢或坐骨神經(jīng)）22Theevaluationofthefibularheadorproximaltibiofibularorhigherisperformedwithmovementsintheanteroposteriordirection,butaftertheleginternallyrotated.評估腓骨頭或者脛腓近端關(guān)節(jié)的方式為小腿內(nèi)旋后前-后向的活動Dependingonthemovementisrestrictedappointthedysfunctionsofthefibularheadin:根據(jù)運動的受限點判斷腓骨頭的功能失常

anteriority向前

posteriority向后Theevaluationofthelateralmalleolusordistaltibialfibularisdonebyinducingmovementtowardtheanterior-afterwardness.評估外踝或者脛腓遠端關(guān)節(jié)的方式為前后向活動Dependingonthemovementisrestrictedappointthemalfunctioningofthelateralmalleolusin:根據(jù)運動受限點判斷外踝功能失常anteriority向前posteriority向后Assessmentoftibiofibular脛腓關(guān)節(jié)評估23Fibularheadinanteriority腓骨頭向前（功能失常）ThrusttecniqueThrust技術(shù)Positionthepatientsupine.患者仰臥Withthehandcaudalintraruotathelowerlimb,thecranialhandinhispalmportion,isplacedabovethefibulararticulation.Withtheweightofthebodyisusedtostretchthejoint,thereyoudropbyperformingathrust.靠近足部的手固定下肢，靠近軀干的手掌心放置于腓骨頭關(guān)節(jié)處。利用身體的重量牽伸關(guān)節(jié)，到障礙點時施展thrust。TECHNICALM.E.T.肌肉能量技術(shù)Patientissittingonthecouch.Itactsontheposteriortibialmuscle.患者坐于治療床，主要是脛骨后部肌肉的活動BringthefootpositionSUBVERSIONANDEXTERNALROTATIONwiththecaudalhand.Withthehandplacedinfrontofthecranialfibulararticulationfosterstheposteriorizzazionefibula.操作者遠端手使患者足外翻外旋，另一只手放在近端腓骨頭前，意在使腓骨頭向后回歸正常位AskthepatienttomakeaFLEXFOOTANDREVERSALofthefoot,usingthetechniqueofcontraction-relaxation.Duringtherelaxationfosterposteriorizzazione.Repeatfor4-5times.要求患者做背屈-跖屈的動作，利用收縮放松技術(shù)。在放松時推動腓骨頭向后。重復(fù)4-5次。24TECHNICALM.E.T.肌肉能量技術(shù)Patientissittingonthecouch.Actionistakenonthelongandshortperonealmuscles.患者坐于治療床，主要是腓骨長肌和短肌的活動。BringthefootpositionINVERSIONANDINTERNALROTATIONwiththecaudalhand.Withthecranialhandwiththeindexfingerplacedbehindthefibulararticulationfosterstheanteriorizzazionefibula.治療師用一只手使足部內(nèi)翻內(nèi)旋，另一只手食指放置于腓骨頭關(guān)節(jié)后，調(diào)整向前Askthepatienttoperformadorsiflexionandeversionofthefoot,usingthetechniqueofcontraction-relaxation.Duringtherelaxationfosteranteriorizzazione.Repeatfor4-5times.要求患者踝背屈外翻，利用收縮放松技術(shù)。在放松時推動腓骨頭向前。重復(fù)4-5次Fibularheadinposteriority后腓骨頭25ThrusttechniqueThrust技術(shù)Placethemetatarsalphalangealjointofthehandcranialposteriortothefibularhead.一手放置于跖趾關(guān)節(jié)處，另一只手置于腓骨頭后Graspthetailwithhishandthedistalpartoftheleg.Performaslightexternalrotationoftheleg,soastofacilitatetheanchorageoftheheadofthefibulaarticulationmetatarsal-phalangealjoint.Bringthekneeinflexiontowardsthebodyofthepatientwiththehandcranialthenwedgedagainstthebarriertoperformathrust使小腿輕微外旋，以鎖定腓骨頭和跖趾關(guān)節(jié)，向著患者軀干方向屈膝，然后朝著運動障礙點方向施展thrust26Dysfunctionslateralmalleolus外踝功能失常TECHNICALCORRECTIONOFAFRONTmalleolus前踝調(diào)整技術(shù)TECHNICALDIRECT直接技術(shù)Placethepatientinthesupineposition.患者仰臥Withthefingersofthehandpositionabovetheanklejoint.Tensionthejointandthenyoudroptheweightofthebodyperformingsuchathrusttowardstherear.手指置于踝關(guān)節(jié)處，活動關(guān)節(jié)至最大范圍處（緊張），利用身體重力施展thrust垂直地面向下TECHNICALCORRECTIONOFAREARmalleolus后踝調(diào)整技術(shù)TECHNICALDIRECT直接技術(shù)Placethepatientintheproneposition.患者俯臥Withthefingersofthehandpositionabovetheanklejoint.Tensionarticulationbringingthethighwiththefootindorsiflexionandthenyoudroptheweightofthebodyperformingsuchathrustinthedirectionofthefront.手指放置于踝關(guān)節(jié)處，踝背屈至最大（關(guān)節(jié)緊張），利用身體重力施展thrust垂直于地面向下27Pathophysiologythroughclinicalcases

病理生理學(xué)臨床例證

-LegandFoot–下肢

CLINICALCASE1

臨床例證1TakeCareOsteopathicAcademyMilano-Italy28PatientPresentation

患者概況A38-year-oldmalecomplainsofnumbnessonthedorsumofhisrightfootanddifficultyliftingthefrontpartofthefoot.38歲男性，右足背部感到麻木，抬小腿困難。History

病史Thepreviousdayhewasstuckbyaca

前一天被汽車撞到Noseriousinjuries,butsubsequently:無嚴重外傷但隨后：Numbnessoverthedorsumofhisrightfoot

整個右足背部麻木Havingtomakea“highstep”toavoiddragginghistoeswhenhewalks行走時需提腿防止腳趾劃地Progressivelossoftheabilitytoraisehistoes逐漸失去提腳趾能力ClinicalCase

臨床例證29PhysicalExamination身體檢查Sensorydeprivationtotheentiredorsumoftherightfoot

整個右足背感覺缺失Dorsiflexionandeversionagainstresistanceweakerontherightsidecomparedtotheleftside與左足相比，右足抗阻力背屈與外翻能力較弱Rightfootdropandhighsteppageduringtheswingphaseofgait

右足下垂且擺動期高足Tenderness,edemaandhematomajustdistaltotheheadoftherightfibula右腓骨頭末端壓痛、腫脹、血腫Normaldeeptendonreflexesforthequadricepsandcalcanealtendons股四頭肌與跟腱深反射正常Stablekneeandanklejoints膝關(guān)節(jié)與踝關(guān)節(jié)穩(wěn)定LaboratoryTests實驗室測試Nothingrelevant無明顯癥狀I(lǐng)magingStudies影像學(xué)Radiographicimaging:nondisplacedfractureoftheneckoftherightfibula放射影像學(xué)：右腓骨頭非位移性骨折ClinicalCase

臨床例證30injurytobothdeepandcommonfibularnervecanresultinfootdrop

深層腓神經(jīng)和腓總神經(jīng)受損都會導(dǎo)致足下垂differentialdiagnosisisrequired

需要進一步診斷ClinicalCase

臨床例證ClinicalReasoning臨床病因Thispatientpresentswithsignsandsymptomsindicatingaclinicalconditionoffootdrop癥狀顯示為足下垂ClinicalProblemstoConsider臨床需考慮的問題Anteriorcompartmentsyndrome前骨間癥狀Commonfibularnervetrauma腓總神經(jīng)受損31RelevantAnatomy相關(guān)解剖Skeletalelementsthatcontributetothelateralaspectofkneeregion:膝關(guān)節(jié)側(cè)面的骨骼結(jié)構(gòu)Lateralcondyleofthefemur股骨側(cè)髁Lateralcondyleofthetibia脛骨側(cè)髁Proximalendofthefibula,articulatedwithlateralcondyleofthetibiaandprovidingdistalattachmentforthetendonofbicepsfemorisandthelateralcollateralligamentoftheknee腓骨近端與脛骨側(cè)髁成關(guān)節(jié)，是股二頭肌肌腱和膝側(cè)副韌帶的附著點ClinicalCase

臨床例證3233RelevantAnatomy相關(guān)解剖Commonfibularnerve(L4-S2)palpableontheneckofthefibula腓總神經(jīng)（L4-S2)可在腓骨頸處觸及Nosensorydistribution無感覺神經(jīng)分支Itinnervatestheshortheadofbicepsfemoris

支配股二頭肌短頭Thesubcutaneouspositionofthecommonfibularnerveonthefibularneckmakesitvulnerablewithtraumatothelateralkneeregion由于腓總神經(jīng)在皮下的位置，使其在膝關(guān)節(jié)側(cè)面區(qū)域創(chuàng)傷時易受損Ontheneckofthefibulacommonfibularnervedividesintoterminalbranches腓總神經(jīng)在腓骨頭處分成終末支ClinicalCase

臨床例證34RelevantAnatomy相關(guān)解剖Ontheneckofthefibulacommonfibularnervedividesintoterminalbranches:腓總神經(jīng)在腓骨頭處分成終末支Superficialfibularnerve(L4-S1)腓表皮神經(jīng)Itsuppliessensoryinnervationfromthedistalanterolaterallegandmostofthedorsumofthefoot受小腿前側(cè)面和大部分足背的感覺神經(jīng)支配Itinnervatesthemusclesofthelateralcompartmentoftheleg(fibularislongusandbrevis)支配小腿側(cè)部肌肉（腓長神經(jīng)和腓短神經(jīng)）ClinicalCase

臨床例證35ClinicalCase

臨床例證RelevantAnatomy相關(guān)解剖Ontheneckofthefibulacommonfibularnervedividesintoterminalbranches:腓總神經(jīng)在腓骨頭處分成終末支：Deepfibularnerve(L4-L5)腓深神經(jīng)Itsuppliessensoryinnervationfromtheadjacentsidesoftoes1and2受第1和2腳趾趾間部分的感覺神經(jīng)支配Itinnervatesthemusclesoftheanteriorcompartmentoftheleg(tibialisanterior,extensorlongusdigitorumandhallucis,fibularistertius)and,onthefoot,extensorbrevisdigitorumandhallucis支配小腿前部肌肉（脛骨前肌、趾長伸肌、拇長伸肌、第3腓骨?。┖妥悴康闹憾躺旒?、拇短伸肌36RelevantAnatomy相關(guān)解剖Myofascialcompartmentsoftheleg:腿部肌筋膜Anterior前部Lateral側(cè)部Deepandsuperficialposterior后部深淺ClinicalCase

臨床例證37ClinicalCase

臨床例證AnteriorCompartmentSyndrome

前骨間癥狀Seriousclinicalconditioninwhichexcessiveaccumulationofinterstitialfluidbecauseofedemaorsomedegreeofhemorrhageincreasethepressureinthecompartment由于水腫和出血引起的組織間液增多可導(dǎo)致骨間壓力增加，是嚴重的臨床癥狀。Asthebordersofthecompartmentareinelastic,theincreasedpressuremayresultinasufferingofallthemuscles,nervesandvesselsincluded,withischemiaandlaternecrosisofthesestructures由于骨間組織是無彈性的，壓力的增加會導(dǎo)致區(qū)域內(nèi)所有的肌肉、神經(jīng)及血管受累，組織缺陷或壞死38SignsandSymptoms體征與癥狀SensoryDeficits感覺缺失Withacuteanteriorcompartmentsyndrome,anearlysignmaybethenumbnessfromtheadjacentsidesoftoes1and2(cutaneousdistributionofdeepfibularnerve)急性的前骨間癥狀，早期的體征是第1和2腳趾鄰近部位（深腓神經(jīng)的皮膚分布）麻木Increasingpaininanteriorlegcompartmentthatmayexceedthanthatoftheoriginalinjury

小腿骨間增加的疼痛可能會超過最初損傷的疼痛Severepainespeciallyduringplantarordorsi-flexion特別在跖屈與背屈時劇烈疼痛MotorDeficit運動缺失Weaknessofdorsiflexionofthefoot足踝背屈無力OtherDeficits其他傷害Visiblebulgingofanteriorcompartmentmuscles骨間前部肌肉可見的腫大Skinpalloroveranteriorcompartment骨間前部皮膚蒼白Compartmentpressure>30mmHg骨間壓力大于30mmHgLaboratoryevidenceofrhabdomyolysis研究中出現(xiàn)橫紋肌溶解現(xiàn)象ClinicalCase

臨床例證AnteriorCompartmentSyndrome

前骨間癥狀39Medicalemergencyrequiringimmediatesurgery(fasciotomy)torelieveincreasedcompartmentpressure緊急情況需要立即的手術(shù)（筋膜切開術(shù)）來減輕骨間膜增加的壓力PredisposingFactors可能的原因Traumatoleg,includingfracturesandsurgeryorcastappliedtootightly(acutecompartmentsyndrome)腿部創(chuàng)傷，包括骨折、手術(shù)或者脫位時夾得太緊（急性骨間癥狀）ClinicalCase

臨床例證AnteriorCompartmentSyndrome

前骨間癥狀40PredisposingFactors

發(fā)病誘因Athleticexertion,forexamplerunningordancing(chroniccompartmentsyndrome)運動員勞損，例如跑步或跳舞（慢性骨間癥狀）Rarelyamedicalemergency,signsandsymptomstendtobetransitoryandconservativetreatmentsasdecreasingintensityoftrainingandusingappropriatefootwearmayreduceoreliminatethesyndrome較少的緊急情況，體征與癥狀一般為慢性過渡性，通常保守治療降低訓(xùn)練強度或應(yīng)用足部綁件來減輕消除癥狀ClinicalCase

臨床例證AnteriorCompartmentSyndrome

前骨間癥狀41ClinicalNote:臨床說明AnteriorCompartmentSyndromevs“shinsplints”前骨間癥狀與“脛夾”“Shins