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when writing the assignment you will need to answer this questions:
• Which OKC f(open kinetic chain) indings were clinically significant or outside of normal/expected range? (e.g. restricted ROM (range of motion), STJ (subtler joint)
varus/valgus, FF(Forefoot) varus/valgus)
• Which CKC (close kinetic Chain) findings were clinically significant? (e.g. tibial varum, RCSP (resting calcaneal stand position) excessively everted)
• Was there any difference between NCSP (natural Calcaneal Stand position) and RCSP? Was this difference what you expected?
• Can you explain any patterns of compensation based on your OKC findings?
• Were your “abnormal” findings predominantly in the frontal, sagittal, or transverse plane (based on biomech assessment, FPI, and gait analysis)?
• Compare your rearfoot measurements during stance phase with your CKC static stance assessment. Was this what you expected to find?
• Compare your gait assessment with the classification of foot type based on the Foot Posture Index. Are these consistent?
• Did you notice any asymmetries between right and left sides, especially during gait?
• Did your angular measurements throughout the gait cycle follow a “normal” pattern?
• Give an overall summary of your significant findings.
This all related to the person i will send you pics of. you need also mention if you think there is any kind of deformities or wrong with the persons foot.
. You do not need to repeat the results from the gait analysis and biomechanical exam sheet. Instead you are explaining how the findings interrelate. For example, the
person may have a large forefoot varus in OKC examination. In CKC this may present as an everted RCSP. In gait this may present as an everted calcaneal position
through the contact and midstance phase of gait. Hence, you would link the static and dynamic findings.
BIOMECHANICAL ASSESSMENT
A biomechanical assessment is used to provide a greater understanding of the function of the lower limb. Open kinetic chain (OKC) refers to the talus acting as an
extension of the leg thus allowing the calcaneus to move and therefore the forefoot to follow, and closed kinetic chain (CKC) where the calcaneus moves in the frontal
plane with limited transverse and sagittal plane motion due to ground force reactions. These are essential in the assessment of both structural and functional
characteristics of the foot. The foots main action is to assist shock absorption and propel the body across the ground.
In close evaluation of Alex’ functional and structural foot type many clinically significant findings became apparent including a rearfoot varus deformity, forefoot
varus due to a soft tissue deformity (supinatus), flexible plantar flexed first ray, hallux abducto valgus (HAV), loose midtarsal joint (MTJ) and subtalar joint (STJ)
range of motion and Hagland’s deformity. General findings using the foot posture index, which combines the various features of foot posture into one quantified result
to determine a person’s foot type, indicated overall that Alex has a normal or neutral foot type with a score of 4.
In a non-weight bearing position (OKC) a functional deformity can be seen rather than a structural one. On assessment of Alex’ OKC results it was determined that her
STJ assessment indicated a loose quality of motion bilaterally due to her being hypermobile. Using the Beighton-Carter-Wilkinson scale, a score of 7 out of 9 was
obtained, confirming hypermobility. In turn, a greater angle of ankle dorsiflexion was measured when the knee was in a flexed position compared to when her knee was
extended. Having a tight gastrocnemius muscle is the cause of this. In relation to normal dorsiflexion of the knee (10) the results obtained showed a much higher
angle (approximately 20), which could be a result of her hypermobility. Excessive dorsiflexion and plantarflexion were also obtained at the first metatarsal
phalangeal joint due to her hypermobility.
When measuring STJ neutral (STJ is neither supinated or pronated) a 5 varus angle bilaterally was measured which is a significant finding as it is outside the normal
range (0-3 inverted). STJ varum is a common abnormality referring to the calcaneus being in an inverted position due to ontogenic derotation (Tiberio, 1998). In
addition a STJ normal range of motion was measured with inversion (20) being twice as much as eversion (10) in a 2:1 ratio and total range of motion being 30 (Root
et al, 1997).
In accordance with Root et al (1997) the average STJ axis is 16 to the sagittal plane and 42 to the transverse plane, with motion obtained mainly in the frontal
plane. However, in Alex’ case there is a greater transverse plane motion (abduction/adduction) then frontal or sagittal plane motion concluding that she has a high STJ
axis (>60). This indicates that the more abduction and adduction present causes more leg rotation, more calcaneal motion and postural problems due to her
hypermobility (Price, 2006).
The overall assessment of the MTJ results show loose quality and range of motion with a high oblique axis. The normal oblique axis indicates a 52 to the transverse
plane and 57 to the sagittal plane (Menz, 1995). Referring to the results Alex has greater motion in the transverse plane indicating a high oblique axis. MTJ range of
motion was within normal limits with range of motion decreasing with STJ inversion and decreasing with eversion.
With many structural deformities present it is usually the STJ which tries to compensate, as it is triplanar. Many studies have shown that the most common structural
deformity (98% of population) is a rearfoot varus. A rearfoot varus can be defined as a congenital structural abnormality of the rearfoot in which it is inverted in
relation to a weight-bearing plane, the STJ is in a neutral position and MTJ is maximally pronated (Frowen et al, pg. 86). Rearfoot varus abnormality can be due to STJ
varum and/or tibial varum. Interpreting both the OKC and CKC results it can be seen that Alex has a rearfoot varus deformity of 10 (left) and 9 (right). With the
presence of both a STJ varum (5 bilaterally) and tibial varum (5 and 4) this increases the rearfoot varus angle compared to if only the STJ was in a varus position.
The cause of a rearfoot varum must be determined whether it is a primary (foot in a varus position due to malilignment) or secondary (additional pathology) condition.
In Alex’ rearfoot deformity of 10 and 9 varus angle and total eversion available being 11 and 10 it can be calculated that she has a fully compensated rearfoot
varus as there is sufficient amount of STJ pronation available allowing the calcaneus to rapidly evert until becoming plantigrade (Pickard, 1983). Signs and symptoms
of a fully compensated rearfoot varus deformity include a low arch profile, hypermobility, Hagland’s deformity and HAV. These signs cause the foot to excessively
pronate and unlock the MTJ.
In the OKC examination however a forefoot varus deformity was also present (3 bilaterally). Forefoot varus is a frontal plane deformity in which the plantar surface
of the forefoot is inverted in relation to the plantar surface of the rearfoot when the STJ is in neutral and MTJ is fully pronated (Frowen et al, pg. 88).
Compensation for a forefoot deformity is dependant on the amount of eversion remaining at the STJ.
On further examination it was found that with additional dorsal pressure applied at the talonavicular joint there was a decrease in the angle of the first metatarsal
with respect to the second (1 bilaterally) therefore indicating an acquired soft tissue forefoot supinatus deformity present. Similar to a forefoot varus, forefoot
supinatus relates to the longitudinal axis of the MTJ in which the forefoot is inverted in relation to the rearfoot. Forefoot supinatus will appear as a forefoot varus
however it refers to the resistance to a pronatory force reducing forefoot inversion, while a forefoot varus will resist the pronatory force with forefoot inversion
reduced only at the STJ (Frowen, pg. 89).
The compensatory mechanism Alex displays for this forefoot supinatus is a partially compensated forefoot supinatus bilaterally signifying that the STJ can generate
some pronation, however not enough to compensate and maximally evert the forefoot (Frowen, pg.89). Signs and symptoms of a forefoot deformity include excessive
pronation of the STJ and eversion of the calcaneus, hypermobility, HAV and a slight lesser toe deformity. As mentioned above, total eversion of 11 and 10 was
available at the STJ and she uses 10 and 9 to compensate for her rearfoot varus deformity. This only leaves her with a 1 of bilateral eversion available to
compensate, allowing only partial compensation, as she needs to compensate 3 bilaterally. The remaining 2 must be compensated elsewhere, which can be seen with her
plantarflexed first ray. Being partially compensated this means that the foot proceeds through the normal gait cycle until the middle of midstance where pronation of
the foot continues so that the medial side of the foot can become weight-bearing (Frowen, pg.88).
A plantarflexed first ray compensation mechanism is seen in CKC where the foot can compensate during weight bearing, in this case for a fully compensated rearfoot
varus and a partially compensated forefoot supinatus. A plantarflexed first ray is mainly due to a muscle imbalance, which can be seen as very flexible (beyond the
second) due to her hypermobility.
Contributing factors to Alex’ rearfoot varus and forefoot supinatus deformities are due to her showing clear signs of Hagland’s deformity. Hagland’s deformity is a
retrospective exostosis in which the gastrocnemius-soleus complex decelerates the body at propulsion during gait (Frowen,pg. 338). This was most likely to occur due to
her fully compensated rearfoot varus and forefoot supinatus deformities causing chronic mechanical irritation. In addition, on further examination of Alex’ feet it was
clearly evident that she had stage 2/3 HAV deformity bilaterally which refers to the abduction of the hallux at the first metatarsal phalangeal joint. Predisposing
conditions include excessive and fully compensated STJ pronation, flexible forefoot varus, long second metatarsal and ligament laxity.
In CKC measuring the NCSP it was evident that some heel lift was present. This observation is due to her having tight gastrocnemius as well as a midtarsal collapse
causing excessive pronation.
The overall biomechanical assessment indicated from the neutral calcaneal stance position (NCSP) a 2 and 1 varus angle was present while palpation of the STJ neutral
and tibial positions calculated a 10 and 9 varus angle. The palpated STJ neutral figure was used as this is a closer indication of what should be occurring compared
to the calculated figure, which theoretically shows what it should be. In theory however these two results should be equal. In spite of this, taking into consideration
equipment error (tractograph), perspective error, measurement error, inaccuracy of the bisection lines and holding the patient in a neutral position, could have all
influenced the results obtained.
Further examination of Alex’ gait analysis was performed using Dartfish. Due to Alex having a rearfoot varus and forefoot supinatus this can cause irregular gait
patterns, which need to be taken into consideration. With excessive pronation at the STJ present from the above results this increases the range of motion of the
rearfoot and MTJ which can lead to early resupination and hypermobility and negatively effect propulsion which can be seen.
An overall assessment of the ankle and hip joint range of motion follow a normal gait cycle pattern extending and flexing at particular stages, except in swing phase
where the ankle is still in a plantar flexed position. This is compensated by excessive flexion of the knee joint throughout the gait cycle and abductory twist of the
ankle. The abductory twist is a compensatory mechanism for excessive pronation allowing for ground clearance and early heel lift, due to a tight gastrocnemius muscle
(Norton)
At the STJ both limbs are in a supinated position at initial contact and pronate into a neutral position at midstance, then resupinates at toe-off following a normal
gait cycle. However, resupination occurs early due to her rearfoot varus and forefoot varus deformity. It can be concluded that Alex’ posture during gait found only a
significant right shoulder drop (4-5) was present which could be due to a slight leg length discrepancy and/or muscle imbalance (Sweeting, 2007). Overall, the
findings found in Alex’ gait analysis proved to be within normal limits.
In turn, the amount of error obtain using Dartfish needs to be considered. Perspective error which refers to the change in length of the object when it moves out of
the calibrated plane, parallax error where the object moves away from the optical axis of the camera and difference in stride length, cadence and stance phases on a
treadmill compared to normal gait all need to be taken into consideration when recording results (Kirtley, pg 31,48-49). Additional error may also have been due to the
inaccuracy of the bisection lines.
In addition to the structural and functional abnormalities found above when attempting to produce a negative cast for her foot the presence of her HAV and forefoot
supinatus, as well as the fat pad on the lateral border proved slightly problematic, causing her toe to be in a plantar flexed position and lateral border being pushed
down. Therefore when casting her foot, plantar pressure was applied at both the first metatarsal area and lateral border to produce a neutral or flat surface for the
cast.
In can be concluded that evaluating OKC, CKC and gait analysis findings, significant structural and functional abnormalities were present. The main biomechanical
results showed a fully compensated rearfoot varus with a partially compensated forefoot supinatus, which is compensated by a plantarflexed first ray, hypermobility and
HAV. Results also indicate tight gastrocnemius’ causing early heel lift and an abductory twist. Overall comparing FPI, gait analysis and biomechanical assessment the
major abnormalities were predominantly in the frontal plane (rearfoot varus and forefoot supinatus due to excessive pronation) as well as some transverse plane
(abductory twist). Although overall, using the FPI score, a normal foot type was calculated. With some inaccuracies in measurements it is necessary to consider
measurement error, perspective error, parallax error and human error. Overall a thorough understanding of Alex’ biomechanics can be concluded.
BIBLIOGRAPHY
Frowen, P., O’Donnell, M., Lorimer, D., & Burrow, G. (2010). Neale’s Disorders of the Foot (8th ed.), USA: Elsevier Limited.
Kirtley, C. (2006). Clinical Gait Analysis: Theory and Practice. Philadelphia, USA: Elsevier Limited (pg. 31,48-49).
Menz, H. (1995). Clinical Hindfoot Measurement: A Critical Review of the Literature The Foot, 5:2057-63.
Norton, G. The Unified Theory The Foot Orthotics Laboratory, Retrieved from: http://www.thefootorthoticslaboratory.co.uk/The%20Unified%20Theory.pdf.
Pickard, J. (1983). The Pathomechanics of Rearfoot Varus The Chiropodist, (October), 379-383.
Price, M. (2006). An Introduction to Biomechanics. Retrieved from http://wwwgp-training.net/rheum/gait/gait.htm.
Root, M. et al (1997). Normal and Abnormal Function of the Foot Clinical Biomechanics (Vol II). Los Angelse. Clinical Biomechanics Corporation.
Sweeting, K. (2007). Gait and Posture: Assessment in General Practice Australian Family Physician, 36(6):398-405.
Tiberio, D. (1988). Pathomechanics of Structural Foot Deformities. Journal of the American Physical Therapy Association. 68(12): 1840-1849. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/3194451.
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