足过度旋前对人体力线的影响及治疗方法①

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。

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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