杨平，蔡丽飞



足过度旋前对人体力线的影响及治疗方法①

杨平，蔡丽飞

[摘要]在一个步态周期中，如果旋前超过支撑期25%，可以认为发生过度旋前，可能由于先天和后天因素导致。过度旋前会影响胫骨、膝关节、股骨、脊柱的力线，导致一系列疼痛综合征。舟骨下降高度测试、足部姿势指数是评定足过度旋前的常用方法，临床常基于经验评定。有效的保守治疗方法包括足矫形器、特种鞋、肌力训练和贴扎技术。

[关键词]足；过度旋前；力线；慢性疼痛；足部矫形器；贴扎；综述

作者单位：1.首都医科大学康复医学院，北京市100068；2.中国康复研究中心康复工程研究所，北京市100068。作者简介：杨平(1983-)，女，汉族，山东沂南县人，硕士，助理研究员，主要研究方向：康复工程。E-mail: yangping2005668@163.com。

[本文著录格式]杨平，蔡丽飞.足过度旋前对人体力线的影响及治疗方法[J].中国康复理论与实践, 2016, 22(1): 72-74.

CITED AS: Yang P, Cai LF. Foot overpronation: influence on body alignment and managements (review) [J]. Zhongguo Kangfu Lilun Yu Shijian, 2016, 22(1): 72-74.

1　定义及原因

1.1定义

足部的综合运动包括旋前和旋后[1]。所谓旋前是指足的外翻、外展、背屈，主要发生在距下关节[2]。该关节是一个三平面运动关节，包括矢状面的跖屈/背屈、额状面内翻/外翻、水平面内收/外展。旋前时，跟骨外翻，距骨内收、跖屈。整个踝足部表现为踝背屈、距下关节外翻、跗横关节外展[1]。在一个步态周期中，从足跟触地到支撑中期发生旋前，以减少来自地面的震动。支撑中期足放平时旋前量最大。如果旋前超过一个步态周期支撑期的25%，就可以认为是过度旋前[2-3]。从外观上看，过度旋前时足跟外翻或足内侧纵弓过度降低，足部变长[4]。过度旋前会使蹬离期足部的正常旋后延迟或消失[5]。

1.2原因

过度旋前是对异常足部软组织或骨性结构的代偿[6-7]。多数情况下过度旋前发生在距下关节[6-8]。过度旋前的原因可分为先天性和后天性[9]。

先天性原因可能是胎儿在子宫内位置不当或遗传所致[9]。Rothbart提出，过度旋前与胚胎发育过程中距骨发育异常有关，即距骨头未完全解旋(unwinding)，使距骨旋后(talar supinatus)，引起第一跖骨相对于第二跖骨被抬高、内翻[10]，并将这种足定义为Rothbart足。从外观上看，这种足的第一、二趾间隙变深。当站立承重足部处于解剖中立位时，第一跖列离地面10～30 mm[11]。

后天性原因包括肌肉骨骼系统异常和神经系统异常。前者包括肌力下降、肌肉韧带松弛、双下肢不等长等[4]；后者包括脑瘫、脑外伤、脑卒中、脊髓损伤等。这种代偿性过度旋前通常从幼儿开始站立负重时就已形成[12]。

2　对下肢力线的影响

2.1足正常力线

1977年，Root等提出，应该将足视为一个动态结构，并描述了理想的足部力线[13-14]。从后方观察，小腿下1/3宽度的等分线与跟骨等分线平行或在一条直线上；从前面观察，5个跖骨头所在的平面与跟骨等分线垂直[4,13]。当距下关节处于中立位(neutral position)，跗中关节必须锁住，足部才能处在中立位。步行时，当足处于支撑中期和足趾离地期时，足应在中立位[13-14]。Åström等发现，足在中立位时，小腿下1/3宽度的等分线与跟骨等分线呈外翻2°，前足轻度内翻6°，站立时跟骨轻度外翻7°，胫骨内翻6°(与垂线的夹角)状态[15]。

2.2过度旋前时的力线

过度旋前会影响胫骨、膝关节、股骨、脊柱的力线[4-7]，进一步引起相关肌肉韧带过劳损伤，最终导致足痛、膝痛、下腰痛等慢性疼痛的发生。改变足部受力状态可以改变下肢力线[5]，达到缓解或消除疼痛的目的。

正常足旋前时胫骨内旋，过度旋前会引起胫骨过度内旋[16-20]。跟骨外翻角度与胫骨旋转有密切关系[16]：跟骨外翻角度越大，胫骨内旋角度也越大[18]。支撑初期膝内旋角增加，股骨内旋角增大[19]，髋关节内旋角增加[20]，骨盆前倾角增加[20]，骶骨角、腰椎前凸角、胸椎后凸角均增加[21]。足部过度旋前最大时，胫骨和股骨的内旋不一定达到最大值[22]。双侧跟骨外翻比单侧跟骨外翻导致的骨盆前倾角更大，单侧跟骨外翻会引起骨盆侧向倾斜[23-24]。过度旋前会引起双下肢功能性不等长，进一步引起骨盆倾斜[25]。

2.3与疼痛的关系

足弓降低会增加膝痛、踝痛的风险[26]。过度旋前会增加胫骨内侧压力，导致胫骨内侧压力综合征[18]，也会引起髌股综合征，尤其会增加髌股外侧压力[18,27]。过度旋前与足底筋膜炎、胫后肌腱炎、跖痛症、拇外翻有密切关系[26,28]，它也会增加运动员膝前交叉韧带损伤的风险[29]。过度旋前导致双下肢不等长，引起骨盆倾斜，进而导致慢性下腰痛[30-31]。

3　评估

过度旋前可以使用舟骨下降高度测试(Navicular Drop Test, NDT)[16,22,32-34]、足弓高度[34]，足部姿势指数(Foot Posture Index, FPI)[35-39]、休息位跟骨外翻角度(resting calcaneal eversion)和纵弓角度(the longitudinal arch angle)[16,22]等方法进行评定。其中NDT和FPI是常用的两种方法。

NDT是指双足站立时，舟骨结节从距下关节中立位到跟骨休息位(即放松站立的位置)时下降的高度。Brody提出舟骨下降高度超过15 mm可以认为足部发生过度旋前，但是没有证明[32]。

FPI共有6项测试内容，前足和后足各3项，所有测试均在受试者双足放松站立时完成[36-39]，可用于成人和儿童[37]，每项测试得分为-2～2分。后足测试包括触摸距骨头(足的内外侧是否可触摸到距骨头)、外踝上下缘的曲线(两个曲线的凹陷程度对比)、跟骨内外翻(以内翻5°、外翻5°为界)、内侧纵弓的一致性(纵弓弧度)，前足测试包括距舟关节的膨出(该关节的凹陷、膨出)、前足相对后足的内收/外展(能看见外侧脚趾的数量)[36-37,39]。10～12分为重度过度旋前，6～9分为过度旋前，0～5分为中立位，-1～-4分为过度旋后，-5～-12分为重度过度旋后[37,39]。男性和女性FBI评分没有明显差异，老年人和儿童的FBI评分偏高[38]，说明老人和儿童容易发生足过度旋前。

在临床工作中，可以从足的外观、鞋的磨损程度和足的力线等几个方面快速判断足部是否过度旋前。从外观上看，足发生过度旋前时，跟骨外翻，足弓高度降低并变长，前足外展[2]。从旧鞋的磨损看，过度旋前时，足底内侧受力增大，鞋底内侧磨损要比外侧严重；鞋会向内侧倾斜。从足的力线上看，取小腿下1/3宽度的中心(A点)、距骨头中心(B点)、第二跖骨头(C点)，当距下关节处于中立位时，这3点应在一条直线上；过度旋前时，这3点不在一条直线上，通常AB的延长线会止于拇趾内侧[40]。这也是拇外翻与过度旋前有密切关系的原因。

4　治疗

对于足部过度旋前及其引起的慢性疼痛，有效的保守治疗方法包括足矫形器[28,31,41-43]、具有运动控制作用的鞋[42]、肌力训练[28,41,44-45]和贴扎技术[42,46]。

足矫形器可消除引起过度旋前的足部因素，如前足内翻、支撑纵弓[42]，减少下肢异常内旋，使各关节、肌肉、韧带处于相对正常的位置，从而减轻疼痛。

具有运动控制作用的鞋常用于跑步运动员，通过鞋跟外展边或鞋的中底修改，起到减慢足触地后和支撑中期的过度旋前的作用[42]。

贴扎技术使用不同材料贴布，控制足部相应关节的运动，达到控制过度旋前的作用[45]。

定制的足部矫形器效果优于通用矫形器。具有运动控制作用的鞋，鞋跟外展或楔形垫设计劣于双密度中底设计。在贴扎材料中，治疗贴扎(therapeutic adhesive taping)效果最好，无弹性的白色贴布效果最差[42]。

增加足底深层肌肉力量可以增加足弓高度，降低舟骨下降程度[45]，从而减少过度旋前。如“缩足运动”(short foot exercise)通过锻炼足底内在肌的力量减少过度旋前[44]。

5　小结

过度旋前是足部最常见的功能异常，它引起人体姿势的改变，导致慢性疼痛发生。重视过度旋前，在临床治疗中综合使用足部矫形器、贴扎、鞋、肌力训练等方法，对于它引起的各种足部疼痛、膝痛、下腰痛等慢性疼痛能收到良好效果。

[参考文献]

[1]汪家琮.踝关节和足的康复[J].中国康复理论与实践, 2008, 14(12): 1197-1198.

[2] Prior TD. Biomechanical foot function: a podiatric perspective: part 1 [J]. J Bodyw Mov Ther, 1999, 3(2): 74-84.

[3] Buchbinder MR, Napora NJ, Biggs EW. The relationship of abnormal pronation to chondromalacia of the patella in distance runners [J]. J Am Podiatr Assoc, 1979, 69(2): 159-162.

[4] Prior TD. Biomechanical foot function: a podiatric perspective: part 2 [J]. J Bodyw Mov Ther, 1999, 3(3): 169-184.

[5] Khamis S, Yizhar Z. Effect of feet hyperpronation on pelvic alignment in a standing position [J].gait Posture, 2007, 25(1): 127-134.

[6] Root ML, Orien WP, Weed JH. Normal and Abnormal Function of the Foot [M]. Los Angeles: Clinical Biomechanics Corporation, 1977.

[7] Donatelli R. Abnormal biomechanics of the foot and ankle [J]. J Orthop Sports Phys Ther, 1987, 9(1): 11-16.

[8] Duckworth T. The hindfoot and its relation to rotational deformities of the forefoot [J]. Clin Orthop Relat Res, 1983(177): 39-48.

[9] Donatelli R. The Biomechanics of the Foot and Ankle [M]. Philadelphia: FADavis Co., 1996.

[10] Rothbart BA. Etiology of foot hyperpronation: embryological perspectiveEtiology of foot hyperpronation: embryological perspective [J]. Br J Osteopathy, 2003, 2003: 16-17.

[11] Rothbart BA. Postural distortions: the foot connection [J]. Online J Sports Med, 2004. [2015-06-28]. https://www.researchgate.net/publication/228472536.

[12] Cailliet R. Foot and Ankle Pain [M]. Philadelphia: FADavis Co., 1997.

[13] McPoil TG, HuntgC. Evaluation and management of foot and ankle disorders: present problems and future directions [J]. J Orthop Sports Phys Ther, 1995, 21(6): 381-388.

[14] Donatelli RA. Normal biomechanics of the foot and ankle [J]. J Orthop Sports Phys Ther, 1985, 7(3): 91-95.

[15]Åström M, Arvidson T. Alignment and joint motion in the normal foot [J]. J Orthop Sports Phys Ther, 1995, 22(5): 216-222.

[16] Rodrigues P, Chang R, TenBroek T, et al. Evaluating the coupling between foot pronation and tibial internal rotation continuously using vector coding [J]. JAppl Biomech, 2015, 31(2): 88-94.

[17] Neal BS,griffiths IB, DowlinggJ, et al. Static foot posture as a risk factor for lower limb overuse injury: a systematic review and meta-analysis [J]. J Foot Ankle Res, 2014, 7(1): 55.

[18] Barton CJ, Levinger P, Crossley KM, et al. The relationship between rearfoot, tibial and hip kinematics in individuals with patellofemoral pain syndrome [J]. Clin Biomech (Bristol,Avon), 2012, 27(7): 702-705.

[19] Resende RA, Deluzio KJ, Kirkwood RN, et al. Increased unilateral foot pronation affects lower limbs and pelvic biomechanics during walking [J].gait Posture, 2015, 41(2): 395-401.

[20] Khamis S, Yizhar Z. Effect of feet hyperpronation on pelvic alignment in a standing position [J].gait Posture, 2007, 25(1): 127-134.

[21] Farokhmanesh K,ghasemi MS, Saeedi H, et al. Effect of foot hyperpronation on spine alignment, in standing position [J]. Modern Rehabil, 2012, 6(2): 65-70.

[22] Reischl SF, Powers CM, Rao S, et al. Relationship between foot pronation and rotation of the tibia and femur during walking [J]. Foot Ankle Int, 1999, 20(8): 513-520.

[23] Pinto RZA, Souza TR, Trede RG, et al. Bilateral and unilateral increases in calcaneal eversion affect pelvic alignment in standing position [J]. Man Ther, 2008, 13(6): 513-519.

[24] Resende RA, Deluzio KJ, Kirkwood RN, et al. Increased unilateral foot pronation affects lower limbs and pelvic biomechanics during walking [J].gait Posture, 2015, 41(2): 395-401.

[25] Tong JWK, Kong PW. Association between foot type and lower extremity injuries: systematic literature review with meta-analysis [J]. J Orthop Sports Phys Ther, 2013, 43(10): 700-714.

[26] Riskowski JL, Dufour AB, Hagedorn TJ, et al. Associations of foot posture and function to lower extremity pain: results from a population-based foot study [J]. Arthritis Care Res (Hoboken), 2013, 65(11): 1804-1812.

[27] Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model [J]. J Orthop Sports Phys Ther, 1987, 9(4): 160-165.

[28] Stovitz SD, Coetzee JC. Hyperpronation and foot pain: steps toward pain-free feet [J]. Phys Sportsmed, 2004, 32(8): 19-26.

[29] Charrette M. Excessive pronation and knee ligament injuries [J]. Dynamic Chiropractic, 2011, 29: 1-4.

[30] O'Leary CB, Cahill R, Robinson AW, et al. A systematic review: the effects of podiatrical deviations on nonspecific chronic low back pain [J]. J Back Musculoskelet Rehabil, 2012, 26(2): 117-123.

[31] Kendall JC, Bird AR, Azari MF. Foot posture, leg length discrepancy and low back pain－their relationship and clinical management using foot orthoses: an overview [J]. Foot (Edinb), 2014, 24(2): 75-80.

[32] Picciano AM, Rowlands MS, Worrell T. Reliability of open and closed kinetic chain subtalar joint neutral positions and navicular drop test [J]. J Orthop Sports Phys Ther, 1993, 18(4): 553-558.

[33] Menz HB. Alternative techniques for the clinical assessment of foot pronation [J]. JAm Podiatr Med Assoc, 1998, 88(3): 119-129.

[34] McPoil T, Cornwall MW, Abeler MG, et al. The optimal method to assess the vertical mobility of the midfoot: navicular drop versus dorsal arch height difference [J]. Clin Res Foot Ankle, 2013, 1: 104.

[35] Sánchez-Rodríguez R, Martínez-Nova A, Escamilla-Martínez E, et al. Can the Foot Posture Index or their individual criteria predict dynamic plantar pressures? [J].gait Posture, 2012, 36(3): 591-595.

[36] Redmond AC, Crosbie J, Ouvrier RA. Development and validation of a novel rating system for scoring standing foot posture: the Foot Posture Index [J]. Clin Biomech (Bristol,Avon), 2006, 21(1): 89-98.

[37] Morrison SC, Ferrari J. Inter-rater reliability of the Foot Posture Index (FPI-6) in the assessment of the paediatric foot [J]. J Foot Ankle Res, 2009, 2: 26.

[38] Redmond AC, Crane YZ, Menz HB. Normative values for the foot posture index [J]. J Foot Ankle Res, 2008, 1: 6.

[39] Redmond AC. The foot posture index: easy quantification of standing foot posture: six itemversion: FPI- 6: userguide and manual [R]. [2015- 06- 28]. http://www.leeds.ac.uk/medicine/FASTER/fpi. htm.

[40] Najjarine A, Pod-NSW D. Finding NCSP using the NAS anterior lines method [J]. Super Biomech Newsl, 2012, 17: 1-2.

[41] Andreasen J, Mølgaard CM, Christensen M, et al. Exercise therapy and custom-made insoles are effective in patients with excessive pronation and chronic foot pain－A randomized controlled trial [J]. Foot (Edinb), 2013, 23(1): 22-28.

[42] Cheung RTH, Chung RCK, NggYF. Efficacies of different external controls for excessive foot pronation: a meta-analysis [J]. Br J Sports Med, 2011, 45(9): 743-751.

[43] Castro-Méndez A, Munuera PV, Albornoz-Cabello M. The short-term effect of custom-made foot orthoses in subjects with excessive foot pronation and lower back pain: a randomized, double-blinded, clinical trial [J]. Prosthet Orthot Int, 2013, 37(5): 384-390.

[44] Mulligan EP, Cook PG. Effect of plantar intrinsic muscle training on medial longitudinal arch morphology and dynamic function [J]. Man Ther, 2013, 18(5): 425-430.

[45] Menz HB, Dufour AB, Riskowski JL, et al. Foot posture, foot function and low back pain: the Framingham Foot Study [J]. Rheumatology (Oxford), 2013, 52(12): 2275-2282.

[46] Franettovich M, Chapman A, Blanch P, et al. A physiological and psychological basis for anti-pronation taping from a critical review of the literature [J]. Sports Med, 2008, 38(8): 617-631.

Foot Overpronation: Influence on Body Alignment and Managements (review)

YANG Ping, CAI Li-fei
1. Capital Medical University School of Rehabilitation Medicine, Beijing 100068, China; 2. Institute of Rehabilitation Engineering, China Rehabilitation Research Center, Beijing 100068, China
Correspondence to YANG Ping. E-mail: yangping2005668@163.com

Abstract:The foot overpronation is termed as pronation persisting more than 25% of stance phase in a walking cycle, which may result from some antenatal or postnatal conditions. Overpronation would lead to abnormal alignment of ankle, knee, pelvis and spine, and result in a set of syndromes of chronic pain. The Navicular Drop Test and the Foot Posture Index are often used as the assessment tools, however, there are several empirical ways for clinic. Foot orthoses, special shoes, taping and training of muscle strength are effective on overpronation as well as chronic pain.

Key words:feet; overpronation; alignment; chronic pain; foot orthoses; taping; review

(收稿日期：2015-07-28修回日期：2015-09-18)

[中图分类号]R681.8

[文献标识码]A

[文章编号]1006-9771(2016)01-0072-03

基金项目：中央级公益性科研院所基本科研业务费专项资金项目(No.2013CZ-13)。

DOI:10.3969/j.issn.1006-9771.2016.01.015