MODULE 1: Introduction to the

examination of the human body

Session 1: General introduction

INDEX
OBJECTIVES ................................................................................. 3
GLOSSARY ................................................................................... 4
General definitions .................................................................... 4
Foot definitions ........................................................................ 5
INTRODUCTION .......................................................................... 10
Anamnesis ............................................................................. 11
Inspection ............................................................................. 13
Palpation ............................................................................... 14
Locomotor apparatus fuctional research .................................... 16
Anthropometrics ..................................................................... 19
BIBLIOGRAPHY ........................................................................... 20

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OBJECTIVES
The main goals to be attained by the student during these work sessions can be
summarized in the following points:

Be introduced to the different aspects of human body exploration.

Know the different phases of human examination.

Become familiar with the most important observations to be carried out during
the physical examination of the patient.

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GLOSSARY
GENERAL DEFINITIONS
Hyper
The term hyper means to increase something. For instance a hypermobile joint is
one which can rotate a lot more than normal (i.e. it has an abnormally large range of
motion).

Hypo
The term hypo means the opposite to hyper. In other words to use the same
analogy, a hypo mobile joint is one that has a reduce range of motion).

Quintus varus
This is a deformity of the little toe where, rather than being in line with the other toes,
it bends inwards towards the other four toes and the fifth metatarsal head becomes
prominent.

Articular condensation
This is where articular cartilage and underlying boney structures become more
condensed due the effect of diseases such as osteoarthritis.

Hyperlordosis
Hyperlordosis means an increase in the sagittal plane curves in lordotic parts of the
spine which are situated in the lumbar region (lower back) and in the neck.

Kyphosis
Kyphosis is a term used to define the sagittal plane curve of the thoracic spine.

Scoliosis
Scloliosis means lateral curvature of the spine.

Exostosis
An exostosis is the name given to a boney outgrowth.

Recurvatum
This is another word for hyperextension of a joint (i.e. a joint which extends past the
straight position). It is usually used to describe hyperextension of the knee.

Ballottement
This is the name given to excessive fluid being felt just proximal to the knee cap
(patella).

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Active movement
Active movement is that which is produced by the patient themselves using their
muscles without any external help.

Passive movement
Passive movement is that which is produced when external force is applied by an
examiner to move a joint.

Anteversion
Anteversion means to lean forward. Anteversion of the femur occurs where an
abnormal shape of the neck of the femur causes internal rotation of the lower limb
which means the patellae may end up pointed towards each other.

Retroversion
This is the opposite to anteversion and causes external rotation of the hip.

FOOT DEFINITIONS
Planes of motion
There are three main planes of motion at right angles to each other:
In the sagittal plane the foot moves in plantarflexion and dorsiflexion.
In the frontal and transverse planes, foot movement is more complicated and is not
restricted to a single plane.

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Bones of the foot

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Cavus
Cavus, when applied to the foot, means a foot which has a very high medial
longitudinal arch.

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Inversion/Eversion at the heel

This is described at the heel and describes the nature of inclination of the heel bone
(calcaneus) relative to the vertical position. An everted heel (otherwise known as a
valgus heel) is shown in the left hand diagram (in this case it is 7 degrees everted).
The right hand picture shows an inverted heel.

Valgus/Varus

A valgus joint position is defined as one in which the more distal portion of the
joint is angled away from midline, such as in genu valgum (knock knee) or hallux
valgus. With regards to the foot it means that the heel (calcaneus) is in an everted
position (see diagram).

A varus joint position is defined as one in which the more distal portion of the joint
is angled in towards midline, such as in genu varum (bowed knee). With regards to
the foot it means that the heel (calcaneus) is in an inverted position (see
diagram).

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Pronation/Supination

Pronation is defined a position in which the heel of the foot is rolled in (everted)
and also the subtalar joint is everted and plantarflexed and the medial longitudinal
arch is reduced in height.

Supination is the opposite to eversion so that the medial arch is increasing in

height and the heel bone is moving into a less everted position.

Dorsiflexion and plantarflexion

These are terms given when the ankle and foot either moves upwards past 90
degrees so that the foot is pointing upwards (dorsiflexion) or moves so that it is
pointing downwards (plantarflexion).

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INTRODUCTION
There are many methods and techniques that can be used to examine the living body
of patients. The techniques used by the pedorthist/orthotist are restricted to the
examination of the 'exterior' of the body. This examination can normally be carried out
without the aid of technical instruments.
From the medical point of view, orthopedic examination includes following procedures:

Anamnesis (the patients case history)

Clinical examination (static and dynamic):

Static examination:

Lower limb observation and their relative position to the body (such as any
mal-alignment/ deformity)

Palpation

Perimeter measurements and limb-length

Examination of joint mobility (active and passive)

Examination of muscle strength, elasticity and tone

Dynamic examination

Study of human gait

Additional tests:

Laboratory tests

Imaging Methods

Special methods of investigation

Study of usual patient shoes: abrasion of the soles, insoles, the type of
shoe.

Before a pedorthist/orthotist actually starts the examination, it is important to get a

clear idea of exactly which areas of the patient need to be examined. The anamnesis,
alongside the doctors diagnosis, will provide valuable information for conducting a
targeted examination. An anamnesis is a dialogue between the investigator and the
patient. The investigator questions the patient, often with the aid of a questionnaire.
The answers to these questions provide him or her with a clearer picture of the
patient's problems. As a result a more accurate physical examination can be
performed.
In addition to the anamnesis, examination techniques such as inspection, palpation or
functional research are important to enable the pedorthist/orthotist to make an
accurate physical examination of the patient.
Functional research is often accompanied by anthropometry: the measurement of
numerous length and weight dimensions of (parts of) the body. Separate
anthropometric equipment is necessary for an anthropometric examination. In practice
this measurement is often performed by eye and by using manual measurement
using a tape measure (for instance, determining leg length), resulting in less accurate
measurements than that recordable using electronic equipment.
All the above-mentioned methods and techniques are concerned with
measuring/establishing characteristics. Measuring has a somewhat broader definition
in science than in daily speech. When you say: 'This skin is red in colour, which is
taken as a measurement statement; establishing the situation. On the other hand
measuring is clearly more limited than simply observing. Heres a thought experiment
to clarify the point. Get five untrained people to look at the feet of someone with a

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foot complaint and get them to describe what they observe about the feet. What
happens? No-one is able to make observations just like that. If we want to observe,
we have to know what were looking for.
In science, observation and measurement are about consciously and systematically
looking for something. In order to make scientific measurement statements, therefore,
it is absolutely essential that we know in advance exactly what we are looking for.
Prior to the examination we must have a plan, a classification, and from that we can
(want to) establish the reality. When making measurement statements, there should
therefore be a list made up beforehand with the 'potential measurement statements'
so that the actual situation only needs to be ticked on the list. It is difficult to arrive at
this kind of standardised measurement interpretations and how to make a decision
for borderline cases?
The reliability of measurements also plays a major role. If two investigators
independently measure the leg length of a patient, it is entirely possible that they will
not come to the same conclusion. It is even very likely that one investigator will get
different results with repeated measurements of the leg length of one patient.
Measurement statements depend not only on characteristics of the examined object,
but also on other factors; random factors.
Imagine we had an objective way of determining whether the skin was red in colour
(for example, using a photo and a card with standard colours). Lets say that a certain
skin seems to be objectively red in colour. Now if seven of the ten investigators state,
on the basis of their 'subjective' judgement, that this skin was red in colour, while
three said that the skin was not red in colour, then we could maintain that the
judgement concerned was obviously 70% reliable. Reliability can therefore be
expressed as a percentage agreement (preferably agreement with what has been
established objectively).
In publications, one sometimes sees the following: The height of the trial patient was
1.76 0.01 m. That 0.01 m is the standard error of measurement of this
measurement statement. This actually indicates a certain interval, namely that
between 1.75 m and 1.77 m. The reliability of the measurement increases the smaller
the standard error of measurement. The standard error of measurement decreases if
the measurement is performed several times in a row and if one takes the mean result
of all these measurements as an estimate.
As we have established, taking absolutely reliable measurements is not possible, but it
is often feasible to make measurement statements with a 'reasonable degree of
reliability'.

ANAMNESIS
In practice the pedorthist/orthotist often has to proceed armed only with the diagnosis
of the disorder given to the patient by the doctor. This means that he or she must be
able to take a full anamnesis and carry out functional research to gather the data
needed to provide a comprehensive (orthopaedic) custom shoe or inlay prescription. It
is also necessary to undertake an anamnesis and a physical examination in patients
who have come to the fitting room for repeat prescriptions, in order to finally get a
good (orthopaedic) custom shoe prescription.
A good anamnesis is extremely valuable for the subsequent physical examination. The
anamnesis in fact reveals the reason why the patient needs the appliance and also
often discloses what sort of appliance is required. The examination is often a

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confirmation of and supplement to the anamnesis. Never start an examination without

first taking an anamnesis!
The anamnesis (also called a subjective examination) also reveals various issues that
the investigator can explore in more detail. Obviously the investigator starts by asking
the patient questions and thereafter will note down some personal details of the
patient (name, address, age, weight, profession, etc.)
Next, it is important to check whether this information is consistent with the diagnosis
given. Therefore, ask about the cause of the complaint and when it appeared. The
patient may also be asked about the existence of any other disorders that may be of
relevance to the pedorthist/orthotist. For example, the existence of diabetes or joint
wear.
The investigator can then proceed to the most important matter for the subsequent
physical examination, namely the patient's problem. It is important that the
investigator does not start by asking closed questions, like: Where is the pain in your
feet?', but with an open question: What is the problem? Experience teaches us that
asking closed questions at the beginning restricts the patient. Depending on the
response of the patient, closed questions can gradually be introduced. In Session 2 a
full anamnesis protocol is shown.
Dont be satisfied too quickly. If the patient indicates that he has a problem with his
feet, the investigator must then ask about the nature of the problem (for example,
pain or fatigue), whether the foot problem occurs upon exertion or when at rest and
the exact location of the problem in the feet. Dont forget to ask next whether there
are also problems around the feet, and if so, where and when.
During the anamnesis the investigator can also ask the patient about the presence of
skin defects and any potential problems in this regard. For example, wounds, scars,
calluses, etc. The investigator can first ask about the major defects (wounds) and
gradually move on to the smaller defects.
Before writing up the (orthopaedic) custom shoe prescription, it is important to have
some understanding about the way the patient walks. Thus, walking distance with and
without (orthopaedic) pedorthic appliances, and equilibrium and balance while
standing and walking, should always be looked into during the anamnesis.
The patients feeling/sensation is often tested during the examination, but the patient
must definitely be questioned about this during the anamnesis. What is the patients
own opinion about the feeling in his feet?
Previous operations can have major functional consequences and the investigator
needs to be aware of them.
The use of some medicines can affect skin condition, by stimulating atrophy or skin
oedema (e.g. Prednisone). Such medicines such as corticosteroids given to patients
with rheumatoid arthritis can also affect the skin of the feet. The investigator can ask
about the use of these medicines.
Finally, there are a number of disorders, such as rheumatoid arthritis and several
muscular disorders, which can adversely affect the functionality of the hands. The
investigator must therefore ask about the use of hands in the context of coping with
shoe fastenings.

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INSPECTION
It is difficult to begin with a standard data when inspecting the body (contours of the
skin, positions of joints, movement outcomes, etc.) because there is a great variation
in the so called normal (contours of the skin, positions of joints, movement
outcomes, etc.) Inspection can be carried out when the patient is at rest, but also
while moving. It is important, if possible, always to compare the left-hand side of the
body with the right-hand side. This also applies to the follow-up examination. Nor
should the investigator forget to carry out the inspection at various levels, because
certain posture deviations are only visible in one level (for example, overstretching the
knees in the sagittal plane). It is also vital to inspect all sides of the feet thoroughly:
dorsal, plantar, medial and lateral. Remember to look between the toes! Build up an
inspection starting first with an inspection of the whole, moving on to individual sites.
Particular attention should be paid to the following when inspecting the lower leg and
foot:
Skin colour with haemorrhaging disorders colour changes can occur, such as:

White for arterial disorders.

Blue/red for venous flow stoppage.

Brown for surface venous degeneration.

Deep red (and hot, to be verified during palpation) for infections.

Changes to skin surface such as:

Skin atrophy (becomes thinner due to eating disorders, for example).

Local callus or corn formation due to, for example, greater stress.

Calcified nails due, for example, to metabolic disorders.

Eczema.

Wounds or ulcers.

Excessively dry or clammy skin.

The presence of scars.

Reduced hair growth due to, for example, eating disorders or vascular
disease, or locally increased hair growth due to, for example, posttraumatic dystrophy.

Contour changes such as:

Muscle contrast: muscle atrophy due to using muscles less or not at all, or
even hypertrophy due to increased use.

Local swellings, for example, with rheumatic disorders, trauma or the

presence of tumours or exostoses(bony outgrowths).

General (diffuse) swellings (oedema), for example, due to cardiac and

kidney diseases or venous thrombosis.

Posture anomalies such as:

Scoliosis (structured or postural scoliosis), hyperlordosis or hyperkyphosis.

Knee flexion or knee recurvatum.

Varus or valgus posture in hip, knees and feet.

Flat or cavus feet.

Claw or hammer toes.

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PALPATION
Palpation can be used to determine the quality of the underlying tissue.

Skin palpation: we can sense the temperature, skin trophism (dry skin, sweaty
skin...).

Musculoskeletal palpation: We can sense the muscular tone, the presence of

joint effusion (balotement kneecap), localization of maximum pain, continuity
tendons, muscles, which are available palpation.
During palpation sometimes we find phenomena that can be perceived such as
skipping or clicking of the knee due to meniscus lesions, rasping/grating in
arthritic joints during movement, crepitation in the course of tendon
pathologies, pops in the area of the greater trochanter in coxa saltans (audible
and palpable phenomenon) which is repositioning with congenital dislocation of
the hip. Palpation can also find free joint bodies (using mouse joint) if they are
located in a accessible joint (like knee or elbow)

Soft tissues: tumours, tissue stiffness, presence and consistency of resistance

in the soft tissues, the possible fluctuation, indicating the presence of fluid in
the bearing.

Vascular and neurological palpation: it can be also used to assess peripheral

arterial pulsation in limbs and neurological examination (for example, in
diabetic disease the sensitivity is decreased).

For this purpose we use the following terms:

Hard is anything that cannot be pressed in: bone or horn;

Firm-elastic is anything that yields a little elastically but cannot obviously be

pressed in. For example a tendon or ligament;

Firm is anything that does yield but is not elastic, such as a tightly
contracted muscle or a tumour;

Soft is anything that can be distorted, like fat.

Borderline cases are difficult to fit into these categories, so hybrids of the above
terminology are sometimes used.
Uniformity and symmetry should also be checked during palpation. For example,
irregular firm swellings and asymmetry can indicate pathology.
The palpation of an artery is characterised by pulsation (the beating of the artery). It
can be difficult to feel an artery. If too little pressure is applied by the palpating finger,
the vessels are not reached; if too much pressure is applied, you will close the vessel.
The palpation of arteries should be carried out with the fingers, not the thumb,
because the thumb artery is on the touching side. There is a big risk that the
investigator will feel his own heart beat. The arteries in the fingers run along the sides
of the fingers. When checking whether a student is really palpating an artery in the
patient's leg, the radial artery of the patient can be palpated by the instructor, while
the student counts the beats he is palpating out loud. A fluid (or pus) filled area is
characterised by fluctuation (fluid movement). This is revealed by laying two fingers
on it. When pressing in one of the fingers, the other should rise by itself. If this
happens in two directions perpendicular to each other, then there is fluctuation.
It could be said that there is not much reliability in palpation either. Experts can come
to different verdicts on the basis of the same discovery.

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For diagnostic procedures it is often important to establish whether certain palpations

are painful. There are significant possibilities for interpretation possibilities in this
regard. One will indicate pain far more readily than another, something may be more
painful under one set of certain circumstances than another, and pain in a specific
place does not always point to pathology in that same place.
Attention should be paid to the following, particularly when palpating the lower leg and
foot:
Temperature:

Higher locally, for example, in gout or Charcot foot arthropathy;

Higher overall, for example, in infections;

Lower, for example, when there is reduced action of the arteries or in

reduced activity of the lower leg musculature.

The palpation of the skin temperature of the patients feet is carried out on the dorsal
side of the foot. The palpation is conducted using the back of the hands. This part of
the hands is the most sensitive in terms of observing temperature differences. If there
are differences in temperature between both feet this may be an indication of an
underlying pathology. Closer examination (by a specialist) is necessary for establishing
the cause of the temperature differences.
Protective or surface feeling:

Lower, for example, in diabetes mellitus and leprosy.

If the pedorthist/orthotist examines the surface feeling in the patients feet, it is

usually done with his fingers. By applying pressure with one finger on the sole of the
foot, while the patient is not looking, he can ask the patient to describe the location on
the feet where pressure is being applied. This examination should be repeated three
times in succession in the same place and on various places on the foot (toes,
metatarsus, heel, plantar and dorsal) in order to ensure greater reliability for the final
interpretation of the surface feeling that is present. The other foot can then be tested
in the same way.
A more reliable method of determining surface feeling is to use a test instrument and
the accompanying test protocol. The test instrument is a 10 g Semmes Weinstein
monofilament. The test can be demonstrated on the patients forearm. When the
monofilament is bowed into a C-shape against the forearm, the patient should feel a
'little prick (which is not painful). Then ask the patient to tell you whether he feels an
identical little prick when the test is carried out on his feet. When testing the feet, the
test must be done three times in succession on the same site (for example, plantar
side of the first metatarsal head). Then the same site on the other foot is tested. If a
patient with diabetes mellitus gives the right answer at least two times out of the
three, then surface feeling is present.
Arteries:

Reduced palpation, for example in the event of reduced activity of the

major arteries, as in atherosclerosis.

Oedemas:

Diffuse, as with chronic venous insufficiency or lymphoedema.

Local, as with rheumatic disorders.

Pain:

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In the event of pain, first let the patient himself indicate with his finger the exact
location of that pain, before going ahead with palpation!

In the case of corns, overexerted joints, heel spurs.

Crepitation (crackling noise due to rubbing of raw surfaces against one

another):

In joints that are affected by wear and tear. In the foot think of the subtalar
joint and the MTP I joint.

LOCOMOTOR APPARATUS FUCTIONAL RESEARCH

When performing the locomotor system functional examination the (inexperienced)
student can firstly focus on examining individual joints and muscles and muscle
groups. For this purpose active and passive movements can be investigated and
resistance tests (muscular strength tests) can be conducted. Then the standing and
walking can be examined, so that the whole picture can be interpreted as regards
balance, asymmetry, stability, etc. A seasoned investigator may decide to investigate
the complex gait pattern (gait image) before conducting a more targeted
investigation. It is risky to start with a gait image analysis, because often this leads to
interpretations being made too quickly without more accurate research. Session 2
gives a full functional examination protocol of the various phases of the functional
examination. The various manipulations involved in the functional examination are
discussed in more detail below.
Active movements are movements that are performed by the patient himself. For this
the investigator must be alert to the following:

The active maximum possible range of motion, which is usually stated in

degrees. There is equipment (such as a goniometer) that can be used to
determine the range of motion. Goniometric examination is the examination
of the range of joint mobility. Movement in the joint can be characterized as
a change in the angle between adjacent bones that come together in a
joint. Movements in the joint are possible with the sagittal plane (flexion,
extension) in the frontal plane (abduction, adduction) and in the horizontal
plane (internal and external rotation). Further information will be deeper
explain in Session 2 of Module 1.
These instruments are normally only used for swaying movements and not
for rotations and are only used rarely, because in daily practice range of
motion is usually 'measured by eye'. This is therefore an extremely
unreliable procedure. As an investigator you should always be aware that
there is a great inter-individual variance (differences between persons)
between the normal maximum ranges of motion of joints.

The pain experience during movement may have direct consequences for
the pedorthist as regards the appliances; for example, preventing
movement, by means of an immobilizing appliance.

The willingness to move may be reduced or non-existent for a patient

wishing to avoid pain, for example in rheumatism patients. It may also be
that a patient cannot move, for example, due to paralysis, or pretends that
he cannot fully move.

Movement coordination is affected by a number of disorders; one of them

being spasticity.

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Range of movement
There are two kinds of range of movement, the active and the passive one.
Active range of mobility is the range of movement which can be achieved by the
activity of the muscles around the joint. This mobility can be limited by pain, based on
the soft tissues such as muscles, tendons, ligaments or joint capsule, as well as by
muscle weakness or failure of the innervation.
Passive range of motion is the range of movement, which is performed by the action
of external forces. It gives information about the actual extent of movement. During
the determination of the passive range of motion, the investigator must be aware of
the following:

Compare the passive maximum range of motion that can be achieved, with
the maximum active range of motion.

Compare the pain experience in both passive and active conditions.

The end feel, which is observed by the investigator when the maximum
passive range of motion is obtained. To be able to recognize the end feel,
the investigator should apply another light overpressure during a passive
movement at the end of the range of motion. Each joint has a characteristic
sort of end feel, which can be categorized as follows:
o

Hard like plantar flexion in the ankle joint (bone end feel).

Soft like flexion of the knee joint.

Capsular/elastic like dorsiflexion of the hallux (without pathology).

Muscular strength tests

Resistance tests or muscular strength tests focus on muscles to which resistance is
applied in the absence of movement. Muscular strength can be reduced by pain,
muscle or tendon damage, neurological deterioration or aspects such as infections,
wear, tumours or fractures. The strength test is usually carried out by hand and is
represented using the MRC scale 1, 2, 3, 4 or 5:

0: Absent of contraction when the patient is required to move the muscle.

1: There is a trace of contraction but no movement is achieved. The muscle
contracts and retains approximately 10% of the normal muscle force, but his
strength is not enough to perform the movement.
2: Movement is possible but without the effect of gravity. The muscle contracts
and maintains approximately 25% of normal muscle force, moving the lower
limb. Nevertheless, this movement is not enough for overcoming small
resistance, such as the weight of the tested part of the body. In this case, the
lower limb is examined in a position to avoid gravity, which depends on the
muscle to be explored.
3: Movement is possible with the effect of gravity. The muscle contracts and
maintains approximately 50% of the normal muscle force. In this case, the
muscle is able to execute the complete movement overcoming the gravity, but
not being able to support any other external resistance.
4: Movement is possible with the effect of gravity and external moderate
resistance. The muscle contracts and maintains approximately 75% of the
normal muscle force. The muscle is able to execute the complete movement
overcoming the gravity, and able to support a moderate external resistance.
5: Muscle movement and its strength are completely normal. The muscle
contracts and maintains approximately 100% of the normal muscle force, being
able to support a high external resistance.

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For performing a proper strength test, following recommendations must be taken into
account:

Test the entire range of motion.

The range of motion must be done steadily and excluding swing.
Avoid muscular compensation from other muscles, performing a firmly fixation
without pressing the tendon or muscular belly to be explored.
Resistance must be applied perpendicular to the direction of the motion.
Resistance must be the same during all range of motion.
Resistance should not be applied in more than two joints.

Posture abnormalities
Posture abnormalities can be assessed while the patient is sitting, standing and
walking. In this way the effect of body weight and speed of walking on the seriousness
of the posture abnormalities can be checked. When interpreting posture abnormalities
the direction of the load line must always be assessed in relation to the trunk and
joints of the lower extremities. Most important posture abnormalities are listed below:
Spinal column:
In a healthy patient we can observe in the sagittal plane a physiologic lordosis
(arching forward) in cervical and lumbar spine and a physiologic kyphosis (curvature
of the arched back) in the thoracic spine. The peaks of these curvatures are placed in
C4-C5, T6-T7 and L3-L4. In the frontal plane only small curvatures are considered as
physiologic.
When these curvatures are out of the physiological range, they will be considered as
pathologies:

Sagittal plane:
o

Hyperkyphosis or decreased kyphosis (dorsal rectification).

Hyperlordosis or lumbar/cervical rectification (typically after a car

accident, called whiplash).

Frontal plane:
o

Scoliosis (structured and postural scoliosis).

Hip:

Abnormal anteversion or retroversion angle

Anteflexion position.

Adduction position, etc.

Varus or valgus coxa.

Flexion position (Genu flexum).

Hyperextension position (Genu recurvatum).

Varus or valgus position.

Knee:

Ankle and foot:

Varus or valgus position.

Toe or heel position.

Flat or flexed position, etc.

Toes:

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Claw or hammer toes.

Varus or valgus toes (like hallux abductus valgus or Tailors bunion).

The gait analysis in the F-plane can be observed in the consultation room (or corridor)
by letting the patient walk away and back to the investigator. Following aspects must
be evaluated:

Width of the gait (balance).

Abnormal hip movements (for example, in Trendelenburg gait).

Varus and valgus positions in the hips, knees, ankles and toes.

Direction of the unrolling.

Type of gait: pronator, neutral or supinator footprint.

Symmetry between left and right leg.

Assessment of the load line in relation to the support plane.

The gait analysis in the S-plane can be observed by looking at the patient from the
side while he or she is walking. Following aspects must be evaluated:

Abnormal flexion positions in hips, knees, ankles and toes.

Stability, particularly in the knee (this is how a hyperextension in the knee

can be interpreted).

Unrolling of the foot (for example, a normal and reversed unrolling).

Symmetry between left and right leg.

ANTHROPOMETRICS
Leg length is a dimension that can be measured in the pedorthist/orthotist's fitting
room. The most important reason for measuring the patient's leg length is to ascertain
whether both legs are the same length. Normally you would try to get a horizontal
position of the pelvis in the F-plane.
In practice the clinical leg length is usually determined (Figure 1). The investigator
lays the thumbs on both anterior superior iliac spines and assesses whether the
connection line runs horizontally. If it does not, planks of a known thickness are
placed under the shorter leg. This can help to determine the leg length difference on a
global level. The investigator can also lay both hands on both iliac crests, thereby
getting an idea of the position of the pelvis. These measurements are carried out with
the hands and eyes.
Then, with a measuring tape you can measure the length of the lower limb, which is
determined by fixed points:
The axis of the lower extremity and landmarks are:
A - Spina iliaca anterior superior (SIAS) otherwise known as the anterio superior iliac
spines (ASIS).
B - Trochanter major, otherwise known as the greater trochanter (its peak).
C - Epicondylus medialis tibiale.
D - Malleolus medialis.
E - The tip of the first or second toe.

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

20/20 __ Module 1 Session 1

However, there are two types of dis-symmetries in the legs: functional and structural
dis-symmetry.
A structural dis-symmetry is a real difference of length in one or more bones of the
leg; for example, as seen in poliomyelitis.
A functional or adaptative dis-symmetry is a compensation by the legs because there
are a body structure altered. For example, a patient who has a scoliosis can elevate a
hip to compensate the scoliotic curve, as a result he or she reduces the length in the
leg, but it isnt a real leg deformity. Furthermore, it can be constructed over a period
of time.
Statements like: there is a leg length difference of 0.5 cm to the detriment of the left
are not reliable. Be careful about using this kind of statement. To determine the
exactly difference of length between legs it is
absolutely necessary to do a
radiography in which appears the exact centimeters of difference in one bone, maybe
in the fibula, shin or femur bone.

Figure 1. Hip palpation

Foot length and width and various circumference measurements are also important for
a pedorthist/orthotist. These sizes are often measured using a measuring tape and
foot stick with English and continental shoe sizes added.. The circumference is sized
directly on the foot; the length and width measurements often using a blueprint or
photocopy. It is also possible to measure some length and width sizes with 2D
scanning. It is even possible to use 3D scanning for determining length, width and
circumference sizes.

BIBLIOGRAPHY
NVOS-Orthobanda. ORTHOPEDISCHE
Uitgeverij De Dienst (2002).

ONLINE TRAINING

SCHOENTECHNIEK.

Boek

2:

Orthopedie.